Lacey S, Cohen S, Jacobs M

Discogenic Low Back Pain (DLBP) is a common condition with an unfavourable prognosis and limited treatment options. After experiencing insufficient response to standard conservative care of physical therapy, non-steroidal anti-inflammatory medications and activity modification, three patients with chronic DLBP were treated with intradiscal injection of dehydrated Human Amnion Chorion Membrane (dHACM). Diagnosis was established by Magnetic Resonance Imaging (MRI) revealing disc disease with anatomically concordant pain. Results indicated a trend toward reduced pain as measured by the Numerical Rating Scale for pain (NRS-Pain) and increased function as measured by the Oswestry Disability Index (ODI).

Lacey, S., Cohen, S., & Jacobs, M. (2020). Intradiscal Injection of Dehydrated Human AmnionChorion Membrane for Treatment of Chronic Discogenic Low Back Pain: A Case Series. Journal of Regenerative Medicine. https://doi.org/10.37532/jrgm.2020.9(1).155

Bhatia A, Engle A, Cohen S

Choosing appropriate pharmacotherapy for acute and chronic LBP continues to pose a major challenge to health-care providers and sufferers. Identifying distinct phenotypes that respond to targeted treatments, improving diagnosis to enable mechanism-based rather than symptom-based treatment of pain (e.g. muscle relaxants for muscle spasms, antidepressants for LBP with a neuropathic character), treating concomitant conditions that may undermine effectiveness (e.g. sleep and psychological disorders) and exploring stepped care and interdisciplinary models, while monitoring for adverse effects are promising approaches that need to be studied for comparative-effectiveness against standard of care. The paucity of pharmacologic treatments for LBP has spurred a search for more efficacious and safer medications. Although they have not been extensively studied for back pain per se, intravenous infusion tests designed to identify pain mechanisms and predict response to oral analgesic therapy represents an area ripe for investigation [30]. Nerve growth factor inhibitors, cannabinoids, newer opioids, ketamine, and botulinum toxin have been evaluated in a variety of clinical studies for LBP. The evidence regarding the role of these therapies is mixed and of low quality. Table 2 provides a summary of some of the important studies on these agents in the last decade. Increasing evidence on newer options will help to optimize the treatment of this challenging and growing problem. It is also important to consider non-pharmacological options for LBP such as physical therapy and psychological treatments. Health-care providers should advise their patients with low back pain about non-pharmacological analgesic options that are supported by evidence of efficacy and safety, while informing them that many of them may not respond to currently available treatments, in which case functional restoration in the context of persistent pain may improve their quality of life.

Bhatia, A., Engle, A., & Cohen, S. P. (2020). Current and future pharmacological agents for the treatment of back pain. Expert Opinion on Pharmacotherapy, 21(8), 857–861. https://doi.org/10.1080/14656566.2020.1735353

Zhao Z, Larkin T, Cohen S

The shoulder is one of the most complex joints in the body, with potential pain generators such as the glenohumeral and acromioclavicular joints, multiple bursae, and numerous soft tissue structures to include multiple tendons and muscles. The lifetime prevalence of shoulder pain is estimated at 7% to 67%, with the prevalence variation stemming from differences in study populations and diagnostic criteria. According to some sources, pain arising from subacromial impingement syndrome is the most common source of chronic shoulder pain, though many patients have pain from multiple pathologies and some have pain despite minimal or no radiologic pathology. In the United States, the estimated cost of chronic shoulder pain is largely unknown, though ∼$3 billion dollars are spent each year on the evaluation and management of rotator cuff tears alone. In Australia, the average annual cost per patient with chronic shoulder pain has been estimated at AU$22,378. Yet, despite the high prevalence and economic expenditures on shoulder pain, surgical and nonsurgical treatments are characterized by high failure rates. According to one systematic review, there is no difference in pain or functional outcomes between surgical and nonsurgical management for shoulder impingement syndrome. In this issue of Pain Medicine, Eckmann et al. report their results with radiofrequency (RF) ablation of the terminal sensory articular nerves of the shoulder joint for chronic, refractory shoulder pain.

Zhao, Z., Larkin, T., & Cohen, S. (2020). Reflections on Innovative Interventional Pain-Relieving Procedures: Lessons Learned from Previous Mistakes. Pain Medicine. https://doi.org/10.1093/pm/pnz380