The burden of back pain : evaluation of costs and health outcomes

Background: Back pain is a leading cause of disability in the world. Beyond the negative impact on people’s health and quality of life, back pain is associated with substantial costs both within and outside the health care sector. While there are many alternative strategies for the treatment and management of back pain, there is a lack of knowledge about their effectiveness, costs and cost-effectiveness. Such information could guide decision-makers regarding which treatment strategies to use for back pain. The aim of the thesis was to explore the costs of back pain, and to explore the effectiveness, costs and cost-effectiveness of different treatments for low back pain. Methods: Studies I and II used a clinical trial design, where data from multiple study centres were combined and analysed in order to increase understanding of changes in patient-reported outcome and costs over time. Study III was a systematic mapping of systematic reviews on the effectiveness of various primary care treatments for chronic low back pain (CLBP). Study IV was a register study where data from multiple national registers were combined and productivity losses for patients with back pain were analysed. Results: There were significant productivity losses due to long-term sickness absence and disability pension among individuals of working age who had undergone a first specialist health care visit for back pain. Productivity losses may be affected by sociodemographic factors and it was indicated that individuals with back pain with an additional diagnosis might have higher productivity losses than individuals with only a back pain diagnosis. There was evidence that some primary care treatments (non-steroidal anti-inflammatory drugs, opioids, spinal manipulation, multidisciplinary biopsychosocial rehabilitation, and therapeutic ultrasound) had positive effects on pain and/or function in patients with CLBP. However, there are considerable knowledge gaps for most treatments. There were statistically significant improvements in health outcomes (back pain-related functional limitation, pain intensity, and health-related quality of life) from a 4-week treatment with chiropractic care for patients with non-specific acute or chronic back pain. There were no statistically significant differences in back pain-related functional limitation, pain intensity, health-related quality of life, costs or quality-adjusted life years when physiotherapy, chiropractic care, and the combination of physiotherapy and chiropractic care were compared with advice among patients with non-specific CLBP over a 6-month period. Conclusion: Back pain is associated with large productivity losses for individuals in the working age. Individuals with a first specialist health care visit for back pain have considerable greater productivity losses than those without back pain. Women tend to have higher productivity losses than men, and individuals with at least one other diagnosis tend to have higher productivity losses compared to those with only a back-pain diagnosis. Chiropractic care of patients with acute or chronic back pain may, over a 1-month period, improve health outcomes (back pain-related functional limitation, pain intensity, and health-related quality of life). There were no statistically significant differences when physiotherapy, chiropractic care, and combination treatment were compared with advice, over a 6-month period, in the treatment of patients with CLBP in Sweden. Due to a high dropout rate and low power, these results should be interpreted with caution, and differences between the treatment groups cannot be ruled out. Some primary care treatments had positive effects on pain and/or function for patients with CLBP. However, these effects were usually not clinically important, and there are considerable knowledge gaps for most back pain treatments. In conclusion, there is a great need for high-quality, large-scale studies to further study the effectiveness, costs and cost-effectiveness of primary care treatments for CLBP

Predicting long-term pain by combining brain imaging, genetics and health questionnaire data with Swedish national registries using a prospective superstruct design

Background Long-term pain is a common health problem that results in disability for patients of all ages, leading to an enormous economic burden. Over 20% of the population suffer from long-term pain. Unfortunately, there are no clinical tests that predicts who will develop long-term pain. The overall aim is to predict future pain incidence based on brain function, pain behavior, health status, and genetic variability. Method PrePain utilizes a superstruct design, which involves recruiting participants from ongoing research projects. Eligible individuals for participation in PrePain were over 18 years old and free from long-term pain. During the baseline visit, participants provide pain and health-related questionnaires, undergo structural and functional MRI scans, and provide a saliva sample for DNA extraction. Individual baseline measures are then routinely followed- up via national registries. Result We present quality-assessed data from over 300 participants. The average age was 34 years, and most participants were women (75%). Participants rated their pain sensitivity above average and reported low avoidance. Catastrophizing thoughts during painful episodes were rated as moderate. Assessments of (f)MRI data indicated generally good image quality. In this first follow-up, we found that 45 participants had a pain-related diagnoses. Conclusion Results indicate that a superstruct design is feasible for collecting a large number of high-quality data. The incidence of long-term pain indicates that a sufficient number of participants have been recruited to complete the prediction analyses. PrePain is a unique prospective pain database with a fair prognosis to determine risk factors of long-term pain

Placebo response and media attention in randomized clinical trials assessing cannabis-based therapies for pain: a systematic review and meta-analysis.

IMPORTANCE Persistent pain is a common and disabling health problem that is often difficult to treat. There is an increasing interest in medicinal cannabis for treatment of persistent pain; however, the limited superiority of cannabinoids over placebo in clinical trials suggests that positive expectations may contribute to the improvements. OBJECTIVE To evaluate the size of placebo responses in randomized clinical trials in which cannabinoids were compared with placebo in the treatment of pain and to correlate these responses to objective estimates of media attention. DATA SOURCES A systematic literature search was conducted within the MEDLINE and Embase databases. Studies published until September 2021 were considered. STUDY SELECTION Cannabinoid studies with a double-blind, placebo-controlled design with participants 18 years or older with clinical pain of any duration were included. Studies were excluded if they treated individuals with HIV/AIDS or severe skin disorders. DATA EXTRACTION AND SYNTHESIS The study followed the Preferred Reporting Items for Systematic Review and Meta-analyses reporting guideline. Data were extracted by independent reviewers. Quality assessment was performed using the Risk of Bias 2 tool. Attention and dissemination metrics for each trial were extracted from Altmetric and Crossref. Data were pooled and analyzed using a random-effects statistical model. MAIN OUTCOMES AND MEASURES Change in pain intensity from before to after treatment, measured as bias-corrected standardized mean difference (Hedges g). RESULTS Twenty studies, including 1459 individuals (mean [SD] age, 51 [7] years; age range, 33-62 years; 815 female [56%]), were included. Pain intensity was associated with a significant reduction in response to placebo, with a moderate to large effect size (mean [SE] Hedges g, 0.64 [0.13]; P < .001). Trials with low risk of bias had greater placebo responses (q1 = 5.47; I2 = 87.08; P = .02). The amount of media attention and dissemination linked to each trial was proportionally high, with a strong positive bias, but was not associated with the clinical outcomes. CONCLUSIONS AND RELEVANCE Placebo contributes significantly to pain reduction seen in cannabinoid clinical trials. The positive media attention and wide dissemination may uphold high expectations and shape placebo responses in future trials, which has the potential to affect the outcome of clinical trials, regulatory decisions, clinical practice, and ultimately patient access to cannabinoids for pain relief

Additional file 1: of Effectiveness, costs and cost-effectiveness of chiropractic care and physiotherapy compared with information and advice in the treatment of non-specific chronic low back pain: study protocol for a randomised controlled trial

SPIRIT Checklist: recommended items to address in a clinical trial protocol. (PDF 130 kb