CHRONIC SPINAL PAIN

management of patients with chronic spinal pain conditions when compared to accessing in-person services within the local community. Future studies will also be undertaken to evaluate the attitudes of patients receiving care from the SPSC & MDS Telehealth Clinic. Whilst unable to generalise, patient satisfaction has repeatedly been shown to be high when receiving management for a variety of musculoskeletal conditions via telerehabilitation (Eriksson, Lindström, & Ekenberg, 2011; Moffet et al., 2017), and that patients’ acceptance and satisfaction often exceeds that of the clinicians treating them (Ward, Burns, Theodoros, & Russell, 2013).

The facet or zygapophysial joints of the spine are well innervated by the medial branches of the dorsal rami [11- 15]. Facet joints have been shown capable of causing pain in the neck, upper and mid back, and low back with pain referred to the head or upper extremity, chest wall, and lower extremity in normal volunteers [16-26]. They also have been shown to be a source of pain in patients with chronic spinal pain using diagnostic techniques of known reliability and validity [2,27-44]. Conversely, the reliabil- ity of physical examination in diagnosing the specific cause of back pain has been questioned [45]. Further, it has been shown that medical imaging provides little addi- tional useful in identifying a precise anatomical diagnosis. In the 1990s precision diagnostic blocks were developed, including facet joint blocks, provocative discography, and sacroiliac joint blocks [2]. Facet joints have been impli- cated as a cause of chronic spinal pain in 15% to 45% of patients with chronic low back pain [32-39], 48% of patients with thoracic pain [43], and 54% to 67% of patients with chronic neck pain [39-42]. These figures were based on responses to controlled diagnostic facet joint blocks performed in accordance with the criteria established by the International Association for the Study of Pain (IASP) [46].

interventions first involves patient assessment (history, exam- ination, investigations, screening questionnaires, information from previous health care professionals), from which follows pain options that are relevant and available to the individual patient, which results in a pain management plan that is agreed and understood by both the patient (and their signifi- cant others) and treating practitioner and communicated to the other health care professionals (coaches). If a person in pain does not currently have a well-organized team providing evidence-based care, then their medical service will need to offer suggestions and coordinate local available options to form a virtual health care pain team. Figure 1 flow chart, is an example of the process of care service provision and the patient journey for the management of chronic spinal pain. Although interventional pain procedures have been utilized for many decades, it is not easy to find precise definitions. Specifically, the distinction between diagnostic and therapeu- tic procedures is often opaque, and so we have provided our definitions to reduce miscommunication between health care professionals (definitions are listed at the end of this article). We would like to draw attention to behavioral changes such as non-sweating movements including real-time imag- ing for retraining multifidus and transversus abdominis and daily walking, and mindfulness which may all play a role in reducing fear, anxiety and threat. 14,15 We postulate

view as indicated in published literature [38]. This study had not recorded the history of clinical intervention that participants may have received. It was unclear if the 2 weeks wash out period was sufficient to wash out any potential ef- fects on mechanical properties of muscles induced by inter- ventions. However, this would have minimum effects on the results and conclusions of the present study since it pri- marily concerned the repeatability of parameters. This study did not specifically attempt to blind the assessor as it was unlikely that the results would be influenced by the as- sessors since they were only required to position the probe perpendicular to the skin surface of the test site) and had minimum involvement during the actual recording process. Myotonometer itself is not without limitation. It measures not only the mechanical properties of muscles but also the properties of other tissues, including skin elasticity and sub- cutaneous tissues. Despite the limitation of the technology, it should not impact the reliability analysis since the pri- mary objective of the study was to compare between the two measurements. Further study to investigate the exact spinal tissue that is probed by the myotonometer is recom- mended to improve the clinical application of the device.

PC has not been giving a satisfactory response to the needs of these patients. General practitioners working in PC devote much of their regular workday to seeing pa- tients with CSP, without being quite certain about what the best therapeutic option is in these cases (Pharmaco- logical and non-pharmacological) [8]. The possibilities for referral are multiple, with no certainty that one option is better than the other such as referral to PC physiotherapy, or referral to different specialised care units (traumatol- ogy, rheumatology, neurosurgery, the pain care unit, etc.). Even so, the majority of treatments administered to these patients are focused on the treatment of structures that are considered pain generators (muscles, joints, and sten- osis), and in blocking the nociceptive pathways, in both cases with poor results [9]. Therefore, a new therapeutic approach is necessary for the treatment of these patients, and in this sense, advances in neuroscience that have oc- curred in the past years allow us to know that in CSP, cen- tral pain processing mechanisms are involved in the maintenance and perpetuation of the painful experience [10, 11].

However, there have been no studies to determine what would occur if the recommendation not to order MRI, CT, or bone scans in the absence of red flags were put into practice. What would be the outcome for patients who present with, for example, spinal pain with or with- out other nonspecific symptoms but are not investigated with any of these scans? How many cases of serious spi- nal disorders would be missed? The goal of this study was to determine the outcomes of patients with subacute and chronic spinal pain, or with other clinical concerns about the possibility of a spinal disorder, but who did not undergo advanced imaging (MRI, CT, or bone scans) unless they met an a priori threshold for testing in keep- ing with the spirit of the CWC recommendations. This approach has been shown to be useful in avoiding waste- ful serologic testing in patients with chronic limb pain. 29

Spinal fusion results have been used as a reference stan- dard to determine the prognostic accuracy of PD. However, it should be stressed that neither spinal fusion nor lumbar disk replacement is a reliable and predictable effective treatment for diskogenic LBP. Although PD is used widely as a selection tool for operative treatment, very few studies have reported its prognostic accuracy for surgical outcome. In a recent sys- tematic literature review, 57 only four studies could be identified

For the investigation of possible influencing factors on the variables pain intensity, frequency and localization, the following 13 factors were included in the regression analyses: 1) continuous parameters: age, time spent in front of TV/computer per week, BMI, FFD and 2) binary variables (coding 0/1): gender (male/female), Adams for- ward bending test (absence/presence of rib hump), single leg stance for 10 seconds with closed eyes (possible on both legs/not possible on one or both legs), parental spinal pain (no/yes; no differentiation whether mother and/or father has pain), smoking parents (no/yes; no dif- ferentiation whether mother and/or father smokes), sleep problems (no/yes), headache (no/yes), abdominal pain (no/yes), headache in combination with abdominal pain (no/yes). In addition to the multivariate model, also the values for the unadjusted/crude odds ratio were calculated. A linear regression analysis was conducted to examine the influencing factors on pain intensity. (Multinomial) logistic regression analyses were performed to investigate for pos- sible influence of the factors on pain frequency and pain localization and on the combination of these variables. As there were only 8 adolescents with mild, but frequent back pain, this group was not included in the correspond- ing multinomial logistic regression analysis. For the ana- lyses on pain characteristics, data sets with missing values were excluded from the corresponding analyses (available case-analysis). For the regression analyses, only complete data sets were included (complete case analysis) and the models were checked for multi-collinearity. All analyses were conducted using SPSS 20. The significance level was set at p < 0.05.

In late 1990s, TNF-α was proposed to be one pro-inflam- matory cytokine with a pivotal role in the "immune-to- brain" pathway of communication for pain, and in models of sickness response in general [51,107]. In classic CCI models in rats, increased levels of TNF-α are found in hippocampus [108,109], locus coeruleus [109,110] and red nucleus [111] of brain. Recent data have suggested that TNF-α mediates central mechanisms of neuropathic pain through glial systems. In the central nervous system, glial cells outnumber neurons by as much as 50-fold, and include three relevant types: astrocytes, oligodendrocytes and microglia. Oligodendrocytes not only provide the myelin sheaths that insulate the neurons, they also con- tribute to the actual expansion of neuronal caliber and reorganization of neurofilaments [112]. Astrocytes are the most abundant glial cells and possess the most diverse functions: they can modulate synaptic functions by form- ing a tripartite synapse with pre-synaptic, post-synaptic and extra-synaptic astrocytic contacts with up to 10,000 other neurons [113,114] using glutamate and adenosine as neurotransmitters [115]. It has been suggested that spi- nal astrocytes may play a role in sensitization of chronic pain via activation of the p38-MAPK system [116,117], and may even synapse with microglia, with pre-synaptic neuronal processes and with post-synaptic neuronal structures to form a tetrapartite configuration [118]. Astrocytes also regulate maturation of neurons and syn- patogenesis, hence playing a pivotal role in modulation of neural plasticity [119]. Microglia constitute 15-20% of the total glial population and serve as an immune invigilator for the central nervous system. They originate from tme- sodermal precursor cells of hemopoietic lineage. In response to nerve injury and inflammation, microglia transform into macrophage-like cells [120] that express major histocompatibility complex antigens and secrete pro-inflammatory cytokines, including TNF-α, IL-1 and IL-6 [121,122]; CCL2 and CX3CL1 [53,123], and ATP, which mediate their effects via the p38-mitogen-activated protein kinase (p38-MAPK) system [41,124,125].

Results: Nine RCTs with 684 patients were included in our meta-analysis. Outcomes favor- ing pregabalin included less pain on a 0–10 scale on 1 day [mean difference (MD): –0.87; 95% CI: –1.55 to –0.19; P= 0.01], 3 days (MD: –1.55; 95% CI: –1.93 to –1.18; P< 0.00001), 1 month (MD: –1.58; 95% CI: –2.75 to –0.42; P=0.008), 3 months (MD: –1.69; 95% CI: –2.71 to –0.66; P= 0.001) postoperatively, and less incidence of neuropathic pain (OR: 0.20; 95% CI: 0.05–0.91; P=0.04), less mean morphine consumption (MD: –5.03; 95% CI: –8.06 to –1.99; P= 0.001), but more dizziness (OR: 3.33; 95% CI: 1.36–8.17; P= 0.009), more drowsiness (OR: 8.61; 95% CI: 2.23–33.20; P=0.002), and less constipation (OR: 0.23; 95% CI: 0.09–0.59; P= 0.002). There was no statistical differences in pain score on 7 days (MD:–0.77; 95% CI: –2.38 to 0.84; P=0.35), nausea (OR: 0.73; 95% CI: 0.42–1.26; P=0.26), and vomiting (OR: 0.83; 95% CI: 0.36–1.90; P = 0.65).

Furthermore, participants with marked depressive symp- toms are excluded from eligibility in this study. Affective and functional dimensions are reflected in patients’ impres- sion of change – even when a reduction in pain intensity may be considered clinically minimal [22]. Affective disrup- tions commonly associated with pain may also interfere with an accurate assessment of changes in pain intensity. Our study is intended to provide a comparative inspection of pain during burst and tonic stimulation that is largely independent of affective improvements that may indirectly influence participant’s assessment of therapy. We recognize that a minority of chronic pain patients, as few as 14% by some accounts, present without significant depressive symptoms [23, 24]. Excluding participants with depressive symptoms is not expected to limit generalizability, however, because the population included in this design is expected to provide a conservative estimate of pain relief during stimulation. Any direct or indirect benefits to affective function conferred by burst stimulation would be expected to be additive, not exclusive, to the effects on pain. Thus, the results of this study would be expected to approximate, possibly to a lesser degree, the efficacy of burst stimulation for general clinic populations.

On the basis of these sensitivity analyses, results appear more prominently for those studies with a low RoB because heterogeneity across studies was much less than when all stud- ies were pooled; however, the overall pooled effect between all studies and those with a low RoB were only marginally differ- ent for pain and functional status at all time measurements. It is noteworthy that a small difference in effect was observed for SMT versus interventions thought to be ineffective as op- posed to SMT versus interventions thought to be effective; however, this amounted to a difference of at most, 5 points on a 100-point scale (for pain at 1 month) or 0.3 points in SMD (for functional status at 1 month). However, none of these analyses suggested a clinically relevant effect on pain or func- tional status at any time interval not observed in the primary analyses. Furthermore, with the exception of two studies, 37 , 55

Pain behaviors were measured one day before incision as baseline and days 1, 3, 5, 7, 10, 20, 30, 40, 50, 60, and 70 after incision. The calibrated von Frey filaments were used to assess mechanical hypersensitivity according to our previous study. 20 In brief, mice were placed on an elevated stainless wire mesh floor and were covered with a clear Plexiglas chamber (5 × 5 × 8 cm). Following acclimation for 30 min, the filaments were applied to paws from least to greatest forces (0.08, 0.15, 0.25, 0.41, 0.7, 1.2, and 2.0 g) to determine the paw withdrawal responses to mechanical stimuli. Each monofilament was applied five times to the plantar side of the hindpaw for approximately 1–2 s with a 10 s interval, starting with a lowest force of filament (0.08 g) and continuing in ascending order. A positive response was defined as a sharp withdrawal of hindpaw upon stimulation. The paw withdrawal threshold was calculated as the force at which the positive response occurred in three out of five stimuli.

correlation = 0.051, P = 0.456). There was also no signifi- cant difference for patients aged , 50 years and .50 years (chi-square = 5.349, correlation = 0.072, P = 0.148) and patients aged , 60 years and .60 years (chi-square = 5.349, correlation = 0.0723, P = 0.148). No correlation was explored between the grade of sleep deprivation and age using the regression analysis (P = 0.5071). Strong evidence was found for a difference between pain intensity subgroups with NRS scores less than five and at least five (chi-square = 54.716, correlation = 0.303, P , 0.001). Very strong evidence was found for a difference between pain intensity sub- groups with NRS scores less than five and more than seven (chi-square = 65.664, correlation = 0.474, P , 0.001). There was a significant positive correlation between the grade of sleep deprivation and pain intensity on the NRS (P , 0.00001, β = 0.23637) as well as for chronification grade (P , 0.00001, β = 0.59057) using the regression analysis. Very strong evi- dence was also found for a diagnosis-related relationship with the intensity of sleep deprivation. For the subgroups of patients with chronic osteoporotic vertebral fracture, interver- tebral disc disease, spondylarthritis, spondylolisthesis, spinal stenosis, and failed back surgery syndrome, a chi-square of 32.867, a correlation of 0.164, and a P-value of 0.005 was calculated. Thus, patients with disc disease and failed back surgery syndrome presented a higher prevalence and degree of sleep deprivation. These groups were also tested separately against the collective without these diagnoses. Comparing patients with intervertebral disc disease to patients with other diagnoses, there was only moderate evidence for a relationship to sleep deprivation (chi-square = 9.308, correlation = 0.094, P = 0.024). There was no significant difference between the group of cervical and lumbar disc disease (chi-square = 1.424, correlation = 0.056, P = 0.7), nor was there a significant difference comparing these against the other diagnoses (cervical versus other: chi-square = 1.521, correlation = 0.039, P = 0.677; lumbar versus other: chi-square = 0.753, Table 1 Characteristics of the analyzed cohort (n = 1016)

Cassisi, Lofland, Cole, and Bruehl (2001) cited two studies which supported the factor structure proposed by the authors of the MPI. In another study, Wittink, Turk, Carr, Sukiennik, and Rogers (2004) studied the responses of 424 patients at a chronic pain treatment facility and found that Cronbach’s alpha coefficients for the MPI scales ranged from .69 to .92, indicating good internal consistency. They noted that some MPI scales were sensitive to change following treatment and recommended it as a self-report pain questionnaire with good psychometric properties. Furthermore, the MPI profiles generated by Turk and Rudy (1988) have been replicated in other studies (Rudy, Turk, Zaki, & Curtin, 1989, Strategier, Chwalisz, Altamair, Russell, & Lehmann, 1997) and have been found to be generalizable to other instruments measuring the same constructs as the MPI (Jamieson, Rudy, Penzien, & Mosley, 1994; Strong, Ashton, & Stewart, 1994). Kerns and colleagues (1985) stated that the brevity, clarity, theoretical rationale, and multidimensional focus of the MPI are all assets, and Bradley, Haile, and Jaworski (1992) recommended the MPI as the best instrument for the assessment of chronic pain across multiple aspects of functioning.

There have been few studies evaluating determinants of outcomes in patients receiving SMT for the care of cLBP. Leboeuf-Yde et al., [17] looked at predictors in a cohort of chiropractic patients with persistent low back pain. They found sex, social benefit, severity of pain, duration of continuous pain at first consultation, and additional neck pain predictive of failure to recover in the short term. Most notable was being pain-free at the fourth visit was a strong predictor of recovery at 3 and 12 months. Dougherty et al. [18] modified the clinical prediction rule developed by Flynn et al. [7] so it could be tested in a randomized trial in a chronic patient population. The modified rule was not successful, a cau- tionary tale against using a prediction rule in individuals for which it was not specifically developed. A large practice-based observational study reported in Nyiendo et al.[8] and Haas et al. [9] found the following to be predictive of outcomes: baseline pain and disability, age, history of low back pain, duration of baseline LBP epi- sode, pain below the knee, provider type, income, smok- ing, comorbidity, and chronic depression.

The purpose of the study was to analyse on pain following traumatic spinal cord in- jury, its prevalence, the types of pain present, the common treatments used and their perceived effectiveness in the management of these reported pain types. A cross sec- tional study was carried out at St Giles Rehabilitation Centre and from members of the Spinal Injuries Association of Zimbabwe (SIAZ). A researcher-administered questionnaire was used to collect data from 24 participants with traumatic spinal cord injury. The questionnaire elicited information on demographic data, pain cha- racteristics and the perceived effectiveness of the common treatments used. Among the 24 participants in the study, 17 were males (70.8%) and 7 were females (29.2%). Pain prevalence was 79.2% among the study participants and approximately a fifth (21.03%) of all participants rated their pain as severe. Eight (33.3%) of the partici- pants had neuropathic pain while 11 (45.8%) had both nociceptive and neuropathic pain types. However, no association was found between sex, age, time post injury when tested against the presence of pain (p > 0.05). Weather changes aggravated al- most every type of pain reported. Both pharmacological and non-pharmacological methods were used to manage the pain but their perceived effectiveness was rated as low. The majority of the traumatic spinal cord injured people experienced some pain and this pain was severe in a fifth of all participants. Pain significantly affected their quality of life. Physiotherapists and other medical professionals need to be aware of this and should employ pain reducing modalities and empathy when dealing with these patients.

Another potential source or error could have been the parents’ response to the SMS question. In order to avoid a phone call from a clinician following a pain report, parents may have reported ‘no pain’ despite actual pain reports from the child, which would have caused an under-reporting of spinal pain. Furthermore, it could be a concern that the children and their parents might have changed their behaviour of reporting pain during the study period, since they have answered SMS-questions continously for up to 6 years. However, when comparing to another Danish project with school children (aged 11 – 15) who were not followed with SMS, but simply answered one questionnaire, the prevalences (lifetime prevalence 86%, 1-week prevalence 36% and point preva- lence 17%) seem to be comparable with our results [2]. In addition, the proportion of missing weeks did not in- crease by study year, indicating continued dedication to the project.

Musculoskeletal pain is a frequent complaint of children, is the most common presenting problem of children referred to pediatric rheumatology clinics. Chronic musculoskeletal (MSK) pain in children is responsible for substantial personal impacts and societal costs, but it has not been intensively or systematically researched. The majority of musculoskeletal pain complaints in children are benign in nature and attributable to trauma, overuse, and normal variations in skeletal growth. There is a subset of children in whom chronic pain complaints develop that persist in the absence of physical and laboratory abnormalities including growing Pain, juvenile fibromyalgia, complex regional pain syndrome. During recent years studies of the epidemiology, etiology and rehabilitation of pain and pain-associated disability in children have revealed a large prevalence of clinically relevant pain, and have emphasized the need for early recognition and intervention.

Opioids: The Association of the Scientific Medical Societies in Germany makes no recommendation either for or against the use of weak opioids because of the limited amount of scientific research addressing their use in the treatment of FM. They strongly advise against using strong opioids. The European League Against Rheumatism recommends the weak opioid such as tramadol but not strong opioids. The Canadian Pain Society says that , starting with a weak opioid like tramadol, can be tried but only for patients with moderate to severe pain that is not well-controlled by non-opioid pain- killers. They discourage the use of strong opioids, and only recommend using them while they continue to provide improved pain and functioning. Healthcare providers must monitor patients on opioids for ongoing effectiveness, side effects and possible unwanted drug behaviours (30) . The combination of tramadol and paracetemol has demonstrated efficacy, safety and tolerability (for up to two years in the management of other pain conditions) without the development of tolerance. It is as effective as a combination of codeine (another mild opioid) and paracetamol but produces less sleepiness and constipation (Janda, 1988).