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Item Effect of Medication Optimization vs Cognitive Behavioral Therapy Among US Veterans With Chronic Low Back Pain Receiving Long-term Opioid Therapy: A Randomized Clinical Trial(American Medical Association, 2022-11-01) Bushey, Michael A.; Slaven, James E.; Outcalt, Samantha D.; Kroenke, Kurt; Kempf, Carol; Froman, Amanda; Sargent, Christy; Baecher, Brad; Zillich, Alan J.; Damush, Teresa M.; Saha, Chandan; French, Dustin D.; Bair, Matthew J.; Psychiatry, School of MedicineImportance: Medication management and cognitive behavioral therapy (CBT) are commonly used treatments for chronic low back pain (CLBP). However, little evidence is available comparing the effectiveness of these approaches. Objective: To compare collaborative care medication optimization vs CBT on pain intensity, interference, and other pain-related outcomes. Design, setting, and participants: The Care Management for the Effective Use of Opioids (CAMEO) trial was a 12-month, comparative effectiveness randomized clinical trial with blinded outcome assessment. Recruitment of veterans with CLBP prescribed long-term opioids occurred at 7 Veterans Affairs primary care clinics from September 1, 2011, to December 31, 2014, and follow-up was completed December 31, 2015. Analyses were based on intention to treat in all randomized participants and were performed from March 22, 2015, to November 1, 2021. Interventions: Patients were randomized to receive either collaborative care with nurse care manager-delivered medication optimization (MED group) (n = 131) or psychologist-delivered CBT (CBT group) (n = 130) for 6 months, with check-in visits at 9 months and final outcome assessment at 12 months. Main outcomes and measures: The primary outcome was change in Brief Pain Inventory (BPI) total score, a composite of the pain intensity and interference subscales at 6 (treatment completion) and 12 (follow-up completion) months. Scores on the BPI range from 0 to 10, with higher scores representing greater pain impact and a 30% improvement considered a clinically meaningful treatment response. Secondary outcomes included pain-related disability, pain catastrophizing, self-reported substance misuse, health-related quality of life, depression, and anxiety. Results: A total of 261 patients (241 [92.3%] men; mean [SD] age, 57.9 [9.5] years) were randomized and included in the analysis. Baseline mean (SD) BPI scores in the MED and CBT groups were 6.45 (1.79) and 6.49 (1.67), respectively. Improvements in BPI scores were significantly greater in the MED group at 12 months (between-group difference, -0.54 [95% CI, -1.18 to -0.31]; P = .04) but not at 6 months (between-group difference, -0.46 [95% CI, -0.94 to 0.11]; P = .07). Secondary outcomes did not differ significantly between treatment groups. Conclusions and relevance: In this randomized clinical trial among US veterans with CLBP who were prescribed long-term opioid therapy, collaborative care medication optimization was modestly more effective than CBT in reducing pain impact during the 12-month study. However, this difference may not be clinically meaningful or generalize to nonveteran populations.Item Laser Acupuncture Analgesia on Postpartum Low Back Pain: A Prospective Randomized Controlled Study(Elsevier, 2023-02) Cheng, Hsuesh-Yu; Wu, Bei-Yu; Tung, Tao-Hsin; Shieh, Carol; Liu, Chun-Ting; School of NursingBackground Unresolved postpartum LBP may affect women...s physical and psychological health. Aim To investigate the analgesic effects of laser acupuncture therapy (LAT) for postpartum LBP. Method Postpartum women with LBP were recruited and randomly assigned to the intervention group or the control group from November 2017 to July 2018. The participants in the intervention group received LAT and standard care. The participants in the control group received only standard care. The primary outcome was the Visual Analogue Scale for LBP. Secondary outcomes were limitation of daily activities and physical activity; perceived stress scale; and salivary cortisol values. Results In all, 106 participants were recruited and assigned to the intervention group or the control group. As compared with the control group, the participants in the LAT group had significantly lower intensity of LBP (mean ± SD: 1.21 ± 0.99 vs 3.25 ± 1.14; p < .001), limitations of daily activities (mean ± SD: 3.17 ± 2.09 vs 10.40 ± 4.72; p < .001) and physical activity (mean ± SD: 3.04 ± 2.17 vs 9.79 ± 4.71; p < .001), perceived stress (mean ± SD: 26.13 ± 3.97 vs 28.85 ± 4.26; p = .001), and salivary cortisol levels (mean ± SD: 0.194 ± 0.131 vs 0.280 ± 0.234; p = .02) post-intervention. Conclusions For postpartum LBP, LAT combined with standard care had greater analgesic efficacy, lower perceived stress, lower limitations of daily activities and physical activity, and lower salivary cortisol levels than standard care alone.Item Propionibacterium acnes, Coagulase-Negative Staphylococcus, and the "Biofilm-like" Intervertebral Disc(Wolters Kluwer, 2016-12-15) Coscia, Michael F.; Denys, Gerald A.; Wack, Matthew F.; Department of Pathology and Laboratory Medicine, IU School of MedicineSTUDY DESIGN: Patients scheduled for spinal surgery were screened prospectively for a microbial presence associated with intervertebral disc specimens. Inclusion was limited to patients requiring surgery for any of five conditions: study patients with cervical spine intervertebral herniation (IVH), lumbar spine IVH, lumbar spine discogenic pain, and control patients with idiopathic scoliosis/Scheurermann's kyphosis or trauma/neuromuscular deformity. Exclusion criteria included ongoing systemic infection, abnormal pre-operative white cell counts, documented or suspected spinal infection, or previous surgery to the involved disc. OBJECTIVE: The aim of this study was to test for an association between the presence of a bacterial entity in operated discs and a diagnosis of pathologic disc disease. SUMMARY OF BACKGROUND DATA: An association has been described between microbial colonization and progressive intervertebral disc degeneration in 36 herniation patients undergoing microdiscectomies. A total of 19 patients had positive cultures on long-term incubation, with Propionibacterium acnes present in 84% of discs. MATERIALS AND METHODS: Discs were harvested during surgery, using strict sterile technique. Each disc was divided, with half the sample sealed in a sterile, commercially prepared anaerobic culture transport container, and half fixed in formalin. Live specimens were cultured for bacteria at a university-affiliated laboratory in a blinded fashion. Fixed pathologic specimens were gram-stained and read by a board-certified pathologist. RESULTS: A total of 169 intervertebral discs from 87 patients were evaluated (46 males, 41 females). Positive cultures were noted in 76 of 169 discs (45%), with 34 discs positive for P. acnes and 30 discs positive for Staphylococcus. No pathologic evidence was seen of microorganisms, acute or chronic inflammation, or infection. Pooling the IVH and discogenic pain patients and contrasting them with control patients showed a significant association of IVH with positive bacterial cultures (χ = 15.37; P = 0.000088). CONCLUSION: Endemic bacterial biofilms are significantly associated with IVH and discogenic pain.Item Soft Tissue Manipulation May Attenuate Inflammation, Modulate Pain, and Improve Gait in Conscious Rodents With Induced Low Back Pain(Oxford University Press, 2021) Loghmani, M. Terry; Tobin, Carolyn; Quigley, Colleen; Fennimore, Alanna; Physical Therapy, School of Health and Human SciencesIntroduction: Low back pain (LBP) is common in warfighters. Noninvasive interventions are necessary to expedite return-to-function. Soft tissue manipulation, for example, massage, is a method used to treat LBP. Instrument-assisted soft tissue manipulation (IASTM) uses a rigid device to mobilize the tissue. This study explored the effects of IASTM on pain, function, and biomarkers. Methods: Sprague-Dawley rats (n = 44) were randomized to groups (n = 6/grp): (A) cage control; (B) 3 days (3d) postinjury (inj), untreated; (C) 3d inj, < 30-minute post-IASTM treatment; (D) 3d inj, 2 hours (2h) post-IASTM; (E) 14 days (14d) inj, untreated; (F) 14d inj, < 30-minute post-IASTM; and (G) 14d inj, 2h post-IASTM. Researchers induced unilateral LBP in Sprague-Dawley rats using complete Freund's adjuvant injection. Conscious rodents received IASTM for 5 min/session once at 3 days or 3×/week × 2weeks (6× total) over 14 days. Biomarker plasma levels were determined in all groups, while behavioral outcomes were assessed in two groups, D and G, at three time points: before injury, pre-, and post-IASTM treatment. Circulating mesenchymal stem cell levels were assessed using flow cytometry and cytokine plasma levels assayed. Results: The back pressure pain threshold (PPT) lowered bilaterally at 3 days postinjury (P < .05), suggesting increased pain sensitivity. IASTM treatment lowered PPT more on the injured side (15.8%; P < 0.05). At 14 days, back PPT remained lower but similar side to side. At 3 days, paw PPT increased 34.6% in the contralateral rear limb following treatment (P < .01). Grip strength did not vary significantly. Gait coupling patterns improved significantly (P < .05). Circulating mesenchymal stem cell levels altered significantly postinjury but not with treatment. Neuropeptide Y plasma levels increased significantly at 3 days, 2h post-IASTM (53.2%) (P < .05). Interleukin-6 and tumor necrosis factor-alpha did not vary significantly. At 14 days, regulated on activation, normal T cell expressed and secreted decreased significantly <30-minute post-IASTM (96.1%, P < .002), while IL-10 trended upward at 2h (53.1%; P = .86). Conclusions: LBP increased pain sensitivity and diminished function. IASTM treatment increased pain sensitization acutely in the back but significantly reduced pain sensitivity in the contralateral rear paw. Findings suggest IASTM may positively influence pain modulation and inflammation while improving gait patterns. Soft tissue manipulation may be beneficial as a conservative treatment option for LBP.Item Treatment Preferences for Chronic Low Back Pain: Views of Veterans and Their Providers(Dovepress, 2021-01-27) Belitskaya-Levy, Ilana; Clark, J. David; Shih, Mei-Chiung; Bair, Matthew J.; Medicine, School of MedicinePurpose: This study was conducted to characterize chronic low back pain (cLBP) and to identify treatment histories and preferences for cLBP management among Veterans and primary care providers within the Veterans Affairs (VA) healthcare system. Participants and methods: Veterans with cLBP from five geographically diverse VA medical centers were identified using International Classification of Diseases (ICD) 9 and 10 codes from VA administrative data as were primary care providers at these same sites. From these data, Veterans (200/per site) and providers (160/per site) were selected and mailed surveys. Open-ended interview data were collected from a subset of Veterans and providers. Results: In total, 235 Veterans and 67 providers returned completed surveys. More than 80% of the Veteran respondents had daily back pain for more than 1 year. Most Veterans had tried several treatments for their pain with medications and physical therapy being the most commonly used. Veterans and providers had similar attitudes towards many cLBP treatments with the exception of psychological therapies that were more favored by providers. Open-ended interview data showed that Veterans and providers emphasized the need for multi-component approaches to treatment. Conclusion: Among Veterans, cLBP is typically of sustained duration, is relatively severe, and also interferes significantly with normal functioning. Veterans are experienced with respect to treatments and had similar attitudes towards many cLBP treatments as their providers, especially tailored approaches.Item Utilization of mechanical diagnosis and therapy (MDT) for the treatment of lumbar pain in the presence of known lumbar transverse process fractures: a case study(Taylor & Francis, 2016-05) Elenburg, J.L.; Foley, B.S.; Roberts, K.; Bayliss, A.J.; Medicine, School of MedicineBACKGROUND: Spinal fractures are typically considered a contraindication to mechanical diagnosis and therapy (MDT). OBJECTIVE AND IMPORTANCE: The purpose of this case study is to illustrate how MDT was used safely and effectively to treat lumbar pain in a patient with multiple lumbar transverse process fractures. CLINICAL PRESENTATION: The subject was a 24-year-old female with left L2-5 transverse process fractures, sustained 10 weeks prior in a pedestrian versus motor vehicle accident. INTERVENTION AND TECHNIQUE: After collaboration with her physiatrist, an MDT examination revealed a presentation consistent with the lumbar derangement syndrome. CONCLUSION: After three visits, utilizing patient generated forces with the extension principle of treatment, her pain, Oswestry disability index (ODI) score, and function all improved.