Efficacy and safety of pamidronate in Modic type 1 changes: study protocol for a prospective randomized controlled clinical trial

Evaluation of the efficacy, in terms of pain and disability, of a functional restoration programme in patients with chronic low back pain according to the presence of Modic 1 discopathy

OBJECTIVES

Modic type 1 disc disease (MD1) appears to be related to severe Chronic Low Back Pain (CLBP). Functional Restoration Programmes (FRP) recommended in CLBP may not be suitable for patients with MD1. The main objective was to evaluate the effectiveness of a FRP, on the perceived incapacity and the pain intensity, in patients with non-specific CLBP according to the presence of MD1.

METHODS

We performed a single-centre retrospective cohort study in which 271 patients were included. After one month in the FRP, this programme was considered "successful" if the pain visual analog scale had decreased by at least 20/100 millimetres and if the score of the French version of the Roland-Morris disability questionnaire had decreased by at least 4/24 points.

RESULTS

The 271 patients had an average age of 43.2 (8.0) years and 58.3% were women. Out of our entire population, 128 (47.2%) patients were considered successful, and 51 (18.8%) patients had MD1. In patients without MD1, there was 49.1% success while this rate was 39.2% in those with MD1, but this difference was not statistically significant.

CONCLUSIONS

We found no significant difference in the combination of pain and perceived disability after one month of a FRP in patients with CLBP without MD1 compared to those with CLBP with MD1. It therefore seems legitimate to offer FRP-type rehabilitation in patients with non-specific CLBP with MD1.

Short-term pain evolution in chronic low back pain with Modic type 1 changes treated by a lumbar rigid brace: A retrospective study

BACKGROUND

Blocking the lumbar or lumbosacral spine with a custom-made rigid lumbar brace, based on the mechanical origin of active discopathy, is a therapeutic option for low back pain, but no study has yet defined its applicability in low back pain.

OBJECTIVE

To assess the pain evolution of individuals with non-specific chronic low back pain associated with Modic type 1 changes treated with custom-made rigid lumbar brace.

METHODS

This was a retrospective observational study conducted in the Physical Medicine and Rehabilitation unit at Clermont-Ferrand University Hospital, France, between January 2014 and December 2016. Inclusion criteria were adults with non-specific chronic low back pain associated with Modic type 1 changes on the lumbar or lumbosacral spine confirmed by MRI. Patients had 4 consultations with the physician (baseline, 5 weeks, 3 months, and 5 months). The brace was progressively withdrawn at 3 months. The main outcome was pain improvement of at least 30% at 3 months (visual pain scale). The secondary outcome was an improvement of at least 50%. We also studied the association between pain improvement at the 2 thresholds (30 and 50%) and clinical data, level of Modic type 1 changes, and pain recurrence after withdrawal of the brace.

RESULTS

Among the 174 patients who wore the brace, 62 were included in the study; 49/62 (79%) showed improvement of at least 30% at 3 months. Two months after brace withdrawal, pain recurred for 30/46 patients (16 missing data). No sociodemographic, clinical or radiographic criteria were associated with pain evolution.

CONCLUSION

In the present study, a rigid lumbar brace worn for 3 months was associated with a 30% reduction in pain for 79% of patients with chronic low back pain and active discopathy. However, the retrospective open and uncontrolled design of our study limits our interpretation about a specific treatment effect. A prospective randomized controlled trial is needed to clarify the effect of a rigid lumbar brace in this condition.

Bone mineral density and bone remodeling markers in chronic low back pain patients with active discopathy: A case-control exploratory study

OBJECTIVE

We aimed to compare bone mineral density (BMD) and bone remodeling markers in chronic low back pain (cLBP) patients with and without active discopathy (Modic 1 changes).

DESIGN

We conducted a single center case-control exploratory study. For 18 months, all patients referred to a tertiary care physical medicine and rehabilitation department in France were consecutively screened. Patients fulfilling the inclusion criteria were prospectively enrolled. Cases were defined as cLBP patients with lumbar active discopathy detected on MRI and controls as cLBP patients without active discopathy. Bone mineral density (BMD) at the spine, femoral neck and total femur was assessed by dual-energy X-ray absorptiometry, and bone remodeling markers were assessed in fasting serum samples. Overall, 37 cLBP patients (13 cases and 24 controls) fulfilled inclusion criteria and were included.

RESULTS

The median age was 42.0 years (Q1-Q3: 36.0-51.0) and mean (SD) LBP duration 72.3 (57.4) months. We found that BMD and levels of bone remodeling markers in cLBP patients did not differ with and without active discopathy.

CONCLUSION

Our results do not support the association between active discopathy and systemic bone fragility.

Active discopathy: a clinical reality

In the late 1980s, the description by Modic and colleagues of elementary discovertebral changes detected on MRI (Modic classification) suggested for the first time a possible correlation between anatomical and clinical features in a subgroup of patients with non-specific chronic low back pain. Degenerative disc disease is frequent and usually asymptomatic, but Modic 1 changes in the vertebral endplates adjacent to a degenerated disc are associated with inflammatory-like chronic low back pain and low-grade local and systemic inflammation, which led to the concept of ‘active discopathy’. Active discopathy shares some similarities with acute flares of peripheral osteoarthritis. Likewise, what triggers disc activation and how it self-limits remain unknown. A better understanding of mechanisms underlying disc activation and its self-limitation is of clinical relevance because it may enable the design of more targeted pharmacological and non-pharmacological interventions for the subgroup of patients with chronic low back pain and active discopathy. Here, we narratively review current disc-centred biomechanical and biochemical hypotheses of disc activation and discuss evidence of interactions with adverse personal and environmental factors.