Injection Therapy for Subacute and Chronic Low Back Pain

Article (PDF Available)inSpine 34(1):49-59 · February 2009with49 Reads
DOI: 10.1097/BRS.0b013e3181909558 · Source: PubMed
Abstract
A systematic review of randomized controlled trials (RCTs). To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low back pain. The effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent, and dosage, generally found in RCTs, point to the need for clinically valid comparisons in a literature synthesis. We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases up to March 2007 for relevant trials reported in English, French, German, Dutch, and Nordic languages. We also screened references from trials identified. RCTs on the effects of injection therapy involving epidural, facet, or local sites for subacute or chronic low back pain were included. Studies that compared the effects of intradiscal injections, prolotherapy, or ozone therapy with other treatments were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded. Eighteen trials (1179 participants) were included in this review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender-and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics, and a variety of other drugs. The methodologic quality of the trials was limited with 10 of 18 trials rated as having a high methodologic quality. Statistical pooling was not possible because of clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy. There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.

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    • "Local treatments have been suggested, ranging from intradiscal cortisone injections to arthrodesis [15-20]. The results are, however, controversial [21,22]. These invasive procedures expose the patient to a risk of infection for intradiscal injections and to operating complications for arthrodesis [19]. "
    [Show abstract] [Hide abstract] ABSTRACT: Erosive degenerative disc disease, also known as Modic type 1 changes, is usually characterized by low back pain with an inflammatory pain pattern, as seen in spondyloarthropathies. Intravenous pamidronate has proven to be effective in patients with ankylosing spondylitis who are refractory to nonsteroidal antiinflammatory drugs, and in painful bone diseases in general, such as Paget's disease, fibrous dysplasia or vertebral fractures. We therefore hypothesize that pamidronate would be effective in treating low back pain associated with Modic type 1 changes. This study, called PEPTIDE (short for the French title "Etude Prospective sur l'Efficacite et la tolerance du PamidronaTe dans les dIscopathies Degeneratives Erosives"), will be a double-blind, randomized, placebo-controlled, parallel group, phase two clinical trial. A total of 48 patients will be recruited. These patients will be randomly assigned to one of the two groups, with 24 patients in each group: one group will be given pamidronate and the other a placebo. Pamidronate will be administered at a dose of 90 mg per day for two days consecutively, and every patient, irrespective of treatment group, will be given paracetamol to maintain blinding by preventing drug-induced fever. The primary outcome measure is a between-group difference of 30 points on a 100 mm Visual Analogue Scale (VAS) at three months. Secondary outcome measures are improvement in functional status and the drug's safety. Primary and secondary outcome measures will be assessed at each visit (inclusion, at six weeks, three months, and six months). If the primary goal is not attained, the patient will be offered a rigid or semi-rigid back brace, irrespective of the treatment group. To date, only local treatments, for example intradiscal corticosteroid therapy, lumbar arthrodesis or back braces have been studied in randomized, controlled trials, with controversial results. This trial is currently ongoing and, if conclusive, should provide physicians with an acceptable alternative to those treatments. The results should be publicly available in spring 2015.Trial registration: ClinicalTrials.gov number, NCT01799616.
    Full-text · Article · Apr 2014
    • "The current evidence for management of non-specific chronic low back pain (NSCLBP) reveals that interventions such as manual therapy, exercise, acupuncture , spinal injections and cognitive behavioural therapy are not superior to each other and have a limited long-term impact on the disorder (Assendelft et al., 2004; Furlan et al., 2005; Hayden et al., 2005; Ostelo et al., 2005; Staal et al., 2008). Possible reasons for the failure of current clinical practice to effectively manage NSCLBP are proposed to lie in two main domains: (1) The failure to adequately deal with NSCLBP within a multidimensional biopsychosocial framework (Borkan et al., 2002 ). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another. Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59). Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
    Full-text · Article · Jul 2013
    • "The current evidence for management of non-specific chronic low back pain (NSCLBP) reveals that interventions such as manual therapy, exercise, acupuncture , spinal injections and cognitive behavioural therapy are not superior to each other and have a limited long-term impact on the disorder (Assendelft et al., 2004; Furlan et al., 2005; Hayden et al., 2005; Ostelo et al., 2005; Staal et al., 2008). Possible reasons for the failure of current clinical practice to effectively manage NSCLBP are proposed to lie in two main domains: (1) The failure to adequately deal with NSCLBP within a multidimensional biopsychosocial framework (Borkan et al., 2002 ). "
    Full-text · Dataset · Jan 2013 · European journal of pain (London, England)
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