High-intensity laser therapy in low back pain management: a systematic review with meta-analysis

Low back pain (LBP) is a widespread health issue affecting people globally and is the second leading cause of missed workdays. High-intensity laser therapy (HILT) promises to decrease pain intensity in LBP patients. The aim of this work was to evaluate the effect of HILT in adult LBP patients. We searched for randomized controlled studies (RCTs) published before January of 2023. Our primary outcome was pain intensity, while our secondary outcomes included disability and flexibility scores. We synthesized the evidence using RevMan v.5.4 and assessed methodological quality with the Oxford/Jadad scale and the Cochrane collaboration's risk of bias tool 1. The model favors the HILT group over the control group in terms of pain intensity after treatment (MD with 95% CI is -1.65 [-2.22, -1.09], p-value < 0.00001, I2=67%), Oswestry disability index (MD with 95% CI is -0.67 [-1.22, -0.12], p-value = 0.02, I2=73%), and Roland disability index (MD with 95% CI is -1.36 [-1.76, -0.96], p-value <0.00001, I2=0%). The patients in the high-intensity laser therapy had statistically significantly lower (low back) pain intensity compared to the patients in the control group. Based on three RCTs, our model also showed the positive effect of the HILT on LBP in terms of the Oswestry disability index and Roland disability index.

Short-term clinical efficacy of the pulsed Nd: YAG laser therapy on chronic nonspecific low back pain: A randomized controlled study

BACKGROUND

Chronic non-specific low back pain (LBP) is gradually increasing among populations worldwide and affects their activities. Recently, the Nd:YAG laser has been presented in the rehabilitation field.

OBJECTIVES

This study aims to explore the short-term effects of the Nd:YAG laser on chronic non-specific LBP individuals.

METHODS

Thirty-five individuals with chronic nonspecific LBP were included in the study from December 2019 to March 2020. Randomly, they were categorized to Nd:YAG group (n = 18) and sham laser as a control (n = 17) thrice weekly for a 6-week intervention. Modified Oswestry disability index (MODI), pain disability index (PDI), visual analogue scale (VAS), and lumbar flexion range of motion (ROM) have been assessed pre and post-6 weeks of the intervention.

RESULTS

Significant improvements were observed in the Nd:YAG group (MODI, P < .001; PDI, P = .007; VAS, P < .001; lumbar ROM, P = .002), whereas the sham group showed no significant changes (MODI, P = .451; PDI, P = .339; VAS, P = .107; lumbar ROM, P = .296) after 6-week intervention. Between-group comparisons showed significant differences in tending toward the Nd:YAG group (MODI, P < .001; PDI, P = .046; VAS, P < .001; lumbar ROM, P = .003).

CONCLUSIONS

Regarding the present study outcomes, short-term pulsed Nd:YAG laser (6 weeks) may reduce functional disabilities and pain intensity, and improve the lumbar flexion ROM in patients with chronic nonspecific LBP. Further well-designed randomized controlled studies with large sample sizes should be conducted regarding laser treatment.

A pilot cohort study of lumbar facet joint denervation in patients with chronic low-back pain

INTRODUCTION

Radio-frequency (RF) denervation of the facet joints is a procedure aimed at the nociceptive median branch nerves of the lumbar dorsal rami. Pain signals from the facet joints are carried through these fibres; by ablating these fibres, central signalling can be prevented. This pilot study investigated the clinical effect and feasibility of the procedure at our institution, the Spine Centre of Southern Denmark.

METHODS

Patients with at least 50% pain relief after initial medial branch diagnostic blocks were candidates for RF denervation. Patients were divided into two groups: 1) patients with at least 80% pain relief and 2) patients with between 50% and 79% pain relief after diagnostic blocks. Denervation was performed bilaterally on the three lowest facet joints in the lumbar spine. The primary outcome parameter was visual analogue scale (VAS). Follow-up questionnaires were answered after one week and after three, six and 12 months.

RESULTS

For the whole sample, we found a mean reduction of 43 VAS points after one week. At three months, we found a mean reduction of 25 points. Six-month data showed a mean 19-point reduction. Twelve-month data showed a mean reduction of 17 points. Group 1 showed superior improvements at all follow-up points and after 12 months, we found a mean VAS reduction of 22 points for this group.

CONCLUSIONS

This pilot cohort study found RF denervation of the facet joint to be a promising alternative for patients with chronic low-back pain. The effect persisted at the one-year follow-up; however, the effect diminished over time.

FUNDING

The Danish Rheumatism Association, The A.P. Møller Foundation for the Advancement of Medical Science.

TRIAL REGISTRATION

The study protocol was approved by the ethical committee of Southern Denmark with registration number S-20160070.

Effects of photobiomodulation therapy in patients with chronic non-specific low back pain: protocol for a randomised placebo-controlled trial

INTRODUCTION

Low back pain (LBP) is one of the largest and most frequent public health problems worldwide. Photobiomodulation therapy (PBMT) is a frequently used non-pharmacological therapy for the treatment of musculoskeletal disorders. However, there is little high-quality scientific evidence that demonstrates the effectiveness of PBMT in the treatment of patients with chronic LBP in the short, medium and long term. Therefore, the objective of this clinical trial is to evaluate the effects of PBMT in patients with chronic non-specific LBP in the short, medium and long term.

METHODS AND ANALYSES

This is a prospectively registered, two-arm randomised placebo-controlled trial with blinded patients, assessors and treatment providers. One hundred and forty-eight patients with chronic non-specific LBP will be recruited. Treatment sessions will be provided three times a week for 4 weeks (totaling 12 sessions) with patients receiving either placebo or active PBMT. For ethical reasons, all patients, regardless of treatment allocation, will also receive an information booklet based on 'The Back Book'. Clinical outcomes will be measured at baseline, at the end of treatment, as well as 3, 6 and 12 months after randomisation. The primary outcomes will be pain intensity and disability measured after 12 sessions of treatment. The secondary outcomes will be pain intensity and disability measured at 3, 6 and 12 months after randomisation, in addition to specific disability and global perceived effect in all time points.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee of Universidade Cidade de São Paulo. The results will be disseminated through scientific publications and presentations at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03089424.

Clinical and functional evaluation of patients with acute low back pain and radiculopathy treated with different energy doses of low level laser therapy

BACKGROUND/AIM

The main clinical phenomena in acute low back pain (LBP) with radiculopathy are pain and neurological disorders. Although some studies show that low level laser therapy (LLLT) has the ability to modulate inflammatory processes and relieve acute pain condition, the laser therapy dose protocol has not been yet completely established. The aim of this study was to investigate the effects of three different energy doses of LLLT in patients with acute LBP and radiculopathy.

METHODS

The study included 66 patients with acute LBP and radiculopathy who had been randomly divided into three groups (22 patients each) received three different doses of LLLT. The patients were treated 5 times weekly, for a total of 10 treatments, with the following parameters: wave length 904 nm, frequency 3,000 Hz, average diode power 25 mW; energy dose of 0.1 J per point in the first group, 1 J per point in the second and 4 J per point in the third group; daily treatment time and accumulated energy were 16 s and 0.4 J in the first group, 160 s and 4J in the second group and 640 s and 16 J in the third group, respectively. The parameters of assessment before and after the therapy were: lumbar and leg pain measured by visual analogue scale (VAS), local and general functional changes (Schober test, manual muscle test, straight leg raise test and the modified North American Spine Society-Low Back Pain Outcome Instrument-NASS LBP).

RESULTS

Highly significant improvements (p < 0.01) were noted in all the groups after LLLT with respect to all the investigated parameters. The VAS scores were significantly lower in all the groups without a difference between the groups (p > 0,05). Functional improvements were better in the third group treated with the dose of 4 J per point than in other two groups (p < 0.05).

CONCLUSIONS

Three different energy doses of LLLT were equally effective in alleviating lumbar and leg pain without side effects, but the dose of 4 J per point seemed to be more effective in improving the activities of daily living and lumbar mobility.

Pain and mobility improvement and MDA plasma levels in degenerative osteoarthritis, low back pain, and rheumatoid arthritis after infrared A-irradiation

Infrared (IR)-A irradiation can be useful in back and musculoskeletal pain therapy. In this study joint and vertebral column pain and mobility were measured during two weeks of IR-A irradiation treatment of patients suffering from degenerative osteoarthritis of hip and knee, low back pain, or rheumatoid arthritis. Additionally, before and after IR-A treatment MDA serum levels were measured to check if MDA variations accompany changes in pain intensity and mobility. Two-hundred and seven patients were divided into verum groups getting IR-irradiation, placebo groups getting visible, but not IR irradiation, and groups getting no irradiation. In osteoarthritis significant pain reduction according to Visual Analogue Scale and mobility improvements occurred in the verum group. Even though beneficial mean value changes occurred in the placebo group, the improvements in the placebo and No Irradiation groups were without statistical significance. In low back pain, pain and mobility improvements (by 35-40%) in the verum group were found, too. A delayed (2nd week) mobility improvement in rheumatoid arthritis was seen. However, pain relief was seen immediately. In patients suffering from low back pain or rheumatoid arthritis, the pain and mobility improvements were accompanied by significant changes of MDA serum levels. However, MDA appears not a sensitive biofactor for changes of the pain intensity in degenerative osteoarthritis. Nevertheless, unaffected or lowered MDA levels during intensive IR-A therapy argue against previous reports on free radical formation upon infrared. In conclusion, rapid beneficial effects of IR-A towards musculoskeletal pain and joint mobility loss were demonstrated.

How many days of bed rest for acute low back pain? Objective assessment of trunk function

Bed rest is usually considered an efficient treatment for acute low back pain. However, the optimal duration of bed rest is still being discussed. The recommended periods vary from 2 days to 2 weeks. The duration of optimum length is an important topic given the economical and physiological drawbacks of prolonged inactivity. The purpose of this work is to measure objectively the efficacy of two different durations of bed rest through a dynamometric measure of trunk function. Some 51 male patients, students or self-employed, being treated for acute low back pain were randomized into two groups. Group I was prescribed a bed rest period of 3 days and group II, a period of 7 days. We used a multi-axis isoinertial trunk testing dynamometric device (Isostation B200, Isotechnologies, USA). Patients were all assessed on day 1 and also on day 5 for group I or on day 9 for group II. The variables measured in the sagittal plane were isometric torques in flexion and extension, unresisted range of motion, average dynamic torques and average velocities. Patients were also asked to fill in a visual analogue pain scale on both assessment days. The improvement of all performance measures were important and highly significant (P < 0.001) in both groups. The results of the functional testing and the visual analogue pain scale showed no significant differences between the groups. In these relatively young and motivated patients, a duration of bed rest of 3 days resulted in the same objective functional improvement of trunk function and pain rating as a period of 7 days. This shorter duration should be considered as preferable, given the same objective results but important physiological and economical advantages.

[Preliminary report for treatment of discogenic low back pain with combined percutaneous laser and O2-O3 mixture]

OBJECTIVE

To evaluate the efficacy of percutaneous laser and O2-O3 mixture in treating chronic discogenic low back pain.

METHODS

There were 48 patients included 32 male and 16 female with the mean age of 43.5 years (range, from 21 to 66 years). The duration of symptoms was more than 6 months, all patients were treated with percutaneous laser and O2-O3 mixture under TV monitoring.

RESULTS

Forty-eight patients followed-up showed no severe complications. At 1 week follow up, 8 cases were evaluated as excellent, 28 as good, 8 as fair and 4 as poor by Macnab standard. The excellent and good rate reached 75%. At 3 months follow up, 17 cases were evaluated as excellent, 23 as good, 6 as fair and 2 as poor with the excellent and good rate of 83.3%. At 6 months follow up, 20 cases were evaluated as excellent, 22 as good, 4 as fair and 2 as poor with a total effective rate of 87.5%. At 12 months follow up, 21 cases were evaluated as excellent, 22 as good, 4 as fair and 1 as poor with a total effective rate of 89.6%.

CONCLUSION

Combined percutaneous laser and O3-O3 mixture is an effective and safe method in treating discogenic low back pain.

Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis

BACKGROUND CONTEXT

The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate.

PURPOSE

To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB).

STUDY DESIGN/SETTING

Multicenter, retrospective clinical data analysis.

PATIENT SAMPLE

Two hundred and sixty-two patients with chronic low back pain who underwent l-z RF denervation at three pain clinics.

OUTCOME MEASURES

Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months postprocedure, and global perceived effect (GPE), which considered pain relief, satisfaction and functional improvement.

METHODS

Data were garnered at three centers on 262 patients who underwent l-z RF denervation after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables.

RESULTS

One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic blocks, 56% obtained greater than or equal to 50% relief from RF denervation and 66% had a positive GPE.

CONCLUSIONS

Using more stringent pain relief criteria when selecting patients for l-z joint RF denervation is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment from good candidates.

Low level laser therapy for nonspecific low-back pain

BACKGROUND

Low-back pain (LBP) is a major health problem and a major cause of medical expenses and disablement. Low level laser therapy (LLLT) can be used to treat musculoskeletal disorders such as back pain.

OBJECTIVES

To assess the effects of LLLT in patients with non-specific LBP.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2005, Issue 2), MEDLINE, CINAHL, EMBASE, AMED and PEDro from their start to November 2007 with no language restrictions. We screened references in the included studies and in reviews and conducted citation tracking of identified RCTs and reviews using Science Citation Index. We also contacted content experts.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) investigating LLLT to treat non-specific low-back pain were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed methodological quality using the criteria recommended by the Cochrane Back Review Group and extracted data. Studies were qualitatively and quantitatively analysed according to Cochrane Back Review Group guideline.

MAIN RESULTS

Seven heterogeneous English language RCTs with reasonable quality were included. Three small studies (168 people) separately showed statistically significant but clinically unimportant pain relief for LLLT versus sham therapy for sub-acute and chronic low-back pain at short-term and intermediate-term follow-up (up to six months). One study (56 people) showed that LLLT was more effective than sham at reducing disability in the short term. Three studies (102 people) reported that LLLT plus exercise were not better than exercise, with or without sham in the short-term in reducing pain or disability. Two studies (90 people) reported that LLLT was not more effective than exercise, with or without sham in reducing pain or disability in the short term. Two small trials (151 people) independently found that the relapse rate in the LLLT group was significantly lower than in the control group at the six-month follow-up. No side effects were reported.

AUTHORS' CONCLUSIONS

Based on the heterogeneity of the populations, interventions and comparison groups, we conclude that there are insufficient data to draw firm conclusions on the clinical effect of LLLT for low-back pain. There is a need for further methodologically rigorous RCTs to evaluate the effects of LLLT compared to other treatments, different lengths of treatment, wavelengths and dosages.

[Mechanisms of formation of chronic low back pain relapse and their correction in patients with dorsopathy]

A clinical-neurological, psychological, biochemical and electromyographic study of 40 operated and 40 non-operated patients with chronic low back pain syndrome was conducted before and after treatment. The authors used various modes of administration of xydifonum, a chelate from the group of bisphosphonates, including electrophoretic, peroral and administration in the form of ointment, administered in turn with heparin one to improve the antiplatelet effect, using photopheresis the with the help of the state-of-the art photomatrix LED equipment. The application of Ca2+-modulating properties of xydifonum demonstrate its universality in achieving of analgesic, muscle-relaxing, anxiolytic and antidepressant effects thus allowing to exclude polypragmasy. This is a main difference between this drug and other medications with limited effects. Based on the results obtained, the authors propose a scheme of development of chronic low back pain.

WITHDRAWN: Low level laser therapy for nonspecific low-back pain

BACKGROUND

Low-back pain (LBP) and related disabilities are major public health problems and a major cause of medical expenses, absenteeism and disablement. Low level laser therapy (LLLT) can be used as a therapeutic intervention for musculoskeletal disorders such as back pain.

OBJECTIVES

To assess the effects of LLLT in patients with non-specific low-back pain and to explore the most effective method of administering LLLT for this disorder.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2005, Issue 2), MEDLINE and CINAHL from their start to January 2007 and EMBASE, AMED and PEDro from their start to 2005 with no language restrictions. We screened references in the included studies and in reviews of the literature and conducted citation tracking of identified RCTs and reviews using Science Citation Index. We also contacted content experts.

SELECTION CRITERIA

Only randomised controlled clinical trials (RCTs) investigating low level laser therapy as a light source treatment for non-specific low-back pain were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed methodological quality using the criteria recommended by the Cochrane Back Review Group and extracted data. Consensus was used to resolve disagreements. Clinically and statistically homogeneous studies were pooled using the fixed-effect model; clinically homogeneous and statistically heterogeneous studies were pooled using the random-effects model.

MAIN RESULTS

Six RCTs with reasonable quality were included in the review. All of them were published in English. Because of clinical heterogeneity in study populations, interventions used and reported outcomes, meta-analysis was not possible to determine an overall effect for pain, disability and range of motion. Three studies (n=168) separately showed a significant pain relief effect of LLLT compared to sham therapy for sub-acute and chronic low-back pain. These effects were only observed at short-term and intermediate-term follow-ups. Long-term follow-ups were not reported. There was insufficient evidence to investigate the difference between LLLT and comparison groups for pain-related disability. There is insufficient evidence to determine the effectiveness of LLLT on anterior-posterior lumbar range of motion compared to control group in short-term follow-up. The relapse rate in the LLLT group was significantly lower than in the control group at six months follow-up period according to the findings of two trials. One study (n=50) reported a significant improvement in pain in LLLT group versus exercise therapy.

AUTHORS' CONCLUSIONS

No side effects were reported. However, we conclude that there are insufficient data to draw firm conclusions. There is a need for further methodologically rigorous RCTs to evaluate the effects of LLLT compared to other treatments, different lengths of treatment, different wavelengths and different dosages. Comparison of different LLLT treatments will be more reasonable if dose calculation methods are harmonized.

[Percutaneous discectomy and intradiscal radiofrequency thermocoagulation for low back pain: evaluation according to the best available evidence]

Within the framework of evidence-based medicine, high quality randomized trials and systematic reviews are needed for new medical treatment. Clinicians should conscientiously, explicitly and judiciously use the best current evidence in making decisions about the care of individual patients. This paper summarizes the best available evidence from systematic reviews and randomized controlled trials concerning two minimally invasive procedures: percutaneous discectomy and percutaneous intradiscal radiofrequency thermocoagulation. Percutaneous discectomy is a minimally invasive surgical procedure that treats contained, herniated discs. Specific procedures within the class include: manual percutaneous lumbar discectomy, Automated percutaneous lumbar discectomy (APLD) laser discectomy and nucleoplasty percutaneous intradiscal radiofrequency thermocoagulation is a procedure that allows the controlled delivery of heat to the intervertebral disc via an electrode or coil. Results of systematic reviews were retrieved from four leading evidence-based databases: the National Institute for Clinical Excellence--NICE, which is an independent organization responsible for providing national guidance on treatments, the Cochrane Library, which is the largest library world-wide for systematic reviews and randomized controlled trials, the Center for Review and Dissemination (CRD) at the University of York, which undertakes reviews of research about the effects of interventions in health and social care and finally, a search via Medline. The results from those systematic reviews and randomized trials shows that, at present, unless or until better scientific evidence is available, automated percutaneous discectomy and laser discectomy should be regarded as research techniques. Radiofrequency denervation can relieve pain from neck joints, but may not relieve pain originating from lumbar discs, and its impact on low-back joint pain is uncertain.

Use of pulsed radiofrequency in failed back surgery syndrome

Failed back surgery syndrome (FBSS) is a well-recognized complication of spinal surgery. Pulse radiofrequency of dorsal root ganglion has been recently described for such patients. In this report, pulsed radiofrequency was applied in 3 patients with failed back surgery syndrome, presenting with severe pain. Reasonable to good pain relief was achieved in 2 patients in 6 months follow-up, however, one patient got short-term pain relief. Based on this limited experience in FBSS where conventional and non-conventional treatments are not effective, pulsed radiofrequency may be considered a logical choice.

Low level laser therapy for nonspecific low-back pain

BACKGROUND

Low-back pain (LBP) and related disabilities are major public health problems and a major cause of medical expenses, absenteeism and disablement. Low level laser therapy (LLLT) can be used as a therapeutic intervention for musculoskeletal disorders such as back pain.

OBJECTIVES

To assess the effects of LLLT in patients with non-specific low-back pain and to explore the most effective method of administering LLLT for this disorder.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2005, Issue 2), MEDLINE and CINAHL from their start to January 2007 and EMBASE, AMED and PEDro from their start to 2005 with no language restrictions. We screened references in the included studies and in reviews of the literature and conducted citation tracking of identified RCTs and reviews using Science Citation Index. We also contacted content experts.

SELECTION CRITERIA

Only randomised controlled clinical trials (RCTs) investigating low level laser therapy as a light source treatment for non-specific low-back pain were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed methodological quality using the criteria recommended by the Cochrane Back Review Group and extracted data. Consensus was used to resolve disagreements. Clinically and statistically homogeneous studies were pooled using the fixed-effect model; clinically homogeneous and statistically heterogeneous studies were pooled using the random-effects model.

MAIN RESULTS

Six RCTs with reasonable quality were included in the review. All of them were published in English. There is some evidence of pain relief with LLLT, compared to sham therapy for subacute and chronic low-back pain. These effects were only observed at short-term and intermediate-term follow-ups. Long-term follow-ups were not reported. There was no difference between LLLT and comparison groups for pain-related disability. There is insufficient evidence to determine the effectiveness of LLLT on antero-posterior lumbar range of motion compared to control group in short-term follow-up. The relapse rate in the LLLT group was significantly lower than in the control group at six months follow-up period according to the findings of two trials.

AUTHORS' CONCLUSIONS

No side effects were reported. However, we conclude that there are insufficient data to draw firm conclusions. There is a need for further methodologically rigorous RCTs to evaluate the effects of LLLT compared to other treatments, different lengths of treatment, different wavelengths and different dosages. Comparison of different LLLT treatments will be more reasonable if dose calculation methods are harmonized.

Clinical predictors of success and failure for lumbar facet radiofrequency denervation

OBJECTIVE

To determine the clinical factors associated with the success and failure of radiofrequency denervation of the lumbar facet joints.

METHODS

Clinical data were garnered from 3 academic medical centers on 192 patients with low back pain who underwent radiofrequency denervation after a positive response to diagnostic blocks. Success was defined as >/=50% pain relief lasting at least 6 months. Factors evaluated for their association with outcome included duration of pain, opioid use, symptom location, paraspinal tenderness, pain exacerbated by extension/rotation (ie, facet loading), MRI abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery and levels treated.

RESULTS

The only factor associated with a successful outcome was paraspinal tenderness. Variables that correlated with treatment failure were 'facet loading,' long duration of pain, and previous back surgery.

CONCLUSIONS

It is counterproductive to use 'facet loading' as the sole basis for choosing patients for facet interventions. In patients at high risk for treatment failure, taking additional steps to reduce the rate of false-positive screening blocks may improve outcomes.

In chronic low back pain, low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial

QUESTION

Is low level laser therapy an effective adjuvant intervention for chronic low back pain?

DESIGN

Randomised trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

Sixty-one patients who had low back pain for at least 12 weeks.

INTERVENTION

One group received laser therapy alone, one received laser therapy and exercise, and the third group received placebo laser therapy and exercise. Laser therapy was performed twice a week for 6 weeks.

OUTCOME MEASURES

Outcomes were pain severity measured using a 10-cm visual analogue scale, lumbar range of motion measured by the Schober Test and maximum active flexion, extension and lateral flexion, and disability measured with the Oswestry Disability Index on admission to the study, after 6 weeks of intervention, and after another 6 weeks of no intervention.

RESULTS

There was no greater effect of laser therapy compared with exercise for any outcome, at either 6 or 12 weeks. There was also no greater effect of laser therapy plus exercise compared with exercise for any outcome at 6 weeks. However, in the laser therapy plus exercise group pain had reduced by 1.8 cm (95% CI 0.1 to 3.3, p = 0.03), lumbar range of movement increased by 0.9 cm (95% CI 0.2 to 1.8, p < 0.01) on the Schober Test and by 15 deg (95% CI 5 to 25, p < 0.01) of active flexion, and disability reduced by 9.4 points (95% CI 2.7 to 16.0, p = 0.03) more than in the exercise group at 12 weeks.

CONCLUSION

In chronic low back pain low level laser therapy combined with exercise is more beneficial than exercise alone in the long term.

The histologic effects of pulsed and continuous radiofrequency lesions at 42 degrees C to rat dorsal root ganglion and sciatic nerve

STUDY DESIGN

Experimental histologic study of the effects of radiofrequency (RF) or convective heating of the rat dorsal root ganglion or sciatic nerve to 42 degrees C.

OBJECTIVE

To determine whether treatment causes neuropathologic changes in an effort to explore the mechanisms and safety of pulsed RF pain therapy.

SUMMARY OF BACKGROUND DATA

Clinical data suggest that low temperature pulsed RF energy delivered to the DRG is a safe and effective form of therapy for low back pain. However, the mechanism by which this treatment modifies pain is unclear.

METHODS

A total of 118 Sprague-Dawley rats were divided into five groups for different RF and thermal treatments. All treatments increased tissue temperature to 42 degrees C. Treatments of the DRG included pulsed RF, continuous RF, and conductive heat. The generator output was increased until 42 degrees C was obtained in the tissue and was then maintained for 120 seconds. As a positive control, some rat sciatic nerves were treated with continuous RF lesions at 80 degrees C. Animals were killed for histologic study at 2, 7, or 21 days after treatment. Tissue was fixed in gluteraldehyde and embedded in plastic resin for detailed light microscopic neuropathologic evaluation.

RESULTS

The methods used to heat the tissue to 42 degrees C caused no significant difference in pathology. However, subclinical changes included endoneurial edema caused by alterations in the function of the blood-nerve barrier, fibroblast activation, and collagen deposition. Tissue returned to normal conditions by 7 days in nerve and 21 days in the DRG. These minor structural changes observed at the light microscopic level in normal animals do not exclude the possibility that there would be nonstructural changes in gene expression or cytokine upregulation in injured tissue. Lesions at 80 degrees C caused consistent thermal injury characterized by Wallerian degeneration of nerve fibers.

CONCLUSIONS

The data support the hypothesis that pulsed RF treatment does not rely on thermal injury of neurologic tissue to achieve its effect.

[Electrophysiological changes in a complex treatment of lumbosacral pain syndrome in patients of different age group]

The influence of two methods of treatment (pharmacological and combination with infra-red laser puncture and manual therapy) on clinical picture, electromyographic indices in 165 patients of different age group with lumbosacral radiculitis has been studied by the author. The use of these methods in treatment of such patients is substantiated by the obtained data.

Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain

BACKGROUND AND OBJECTIVES

The aim of this study was to determine whether low power laser therapy (Gallium-Arsenide) is useful or not for the therapy of chronic low back pain (LBP).

STUDY DESIGN/MATERIALS AND METHODS

This study included 75 patients (laser + exercise-25, laser alone-25, and exercise alone-25) with LBP. Visual analogue scale (VAS), Schober test, flexion and lateral flexion measures, Roland Disability Questionnaire (RDQ) and Modified Oswestry Disability Questionnaire (MODQ) were used in the clinical and functional evaluations pre and post therapeutically. A physician, who was not aware of the therapy undertaken, evaluated the patients.

RESULTS

Significant improvements were noted in all groups with respect to all outcome parameters, except lateral flexion (P < 0.05).

CONCLUSIONS

Low power laser therapy seemed to be an effective method in reducing pain and functional disability in the therapy of chronic LBP.

Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials

BACKGROUND AND OBJECTIVES

The use of radiofrequency (RF) procedures in the peripheral nervous system to treat chronic spinal pain has been the subject of controversy. Publications concerned only uncontrolled studies, and irreversible nervous tissue damage was believed to be responsible for the effect, if any. In recent years, randomized, controlled studies have appeared, which have attested to an increasing use of these techniques. This is a systematic review of randomized controlled trials on RF procedures for spinal pain.

METHODS

We performed a standardized literature search for randomized, controlled trials. Three adjudicators independently registered trial methodology and outcome using validated and subject-related instruments. Interadjudicator disagreement was resolved by discussion. It was found necessary to devise additional parameters of study assessment.

RESULTS

Six trials met the inclusion criteria. This small number, along with clinical and technical heterogeneity precluded statistical analysis. All studies, whether high or low quality, reported positive outcomes.

CONCLUSIONS

We conclude that there is moderate evidence that RF lumbar facet denervation is more effective for chronic low back pain than placebo. Limited evidence exists for efficacy of RF neurotomy in chronic cervical zygapophyseal joint pain after flexion-extension injury. There is limited evidence that RF heating of the dorsal root ganglion is more effective than placebo in chronic cervicobrachialgia. We recommend the systematic application of our additional parameter assessments for future evaluations of RF studies. These additional parameters should also be used in the preparation of future trial protocols of RF procedures for the treatment of chronic pain.

[Radiotherapy for pain in chronic, degenerative low back pain syndrome--results of a prospective randomized study]

AIM OF STUDY

A low-dose radiotherapy with 5 Gy on the lumbar spine in patients with chronic low back pain was investigated.

METHOD

31 patients with non-radicular low back pain since three years at the age of at least 50 years (64.3 years on average) were treated. A psychosomatic etiology of pain was excluded. 5 Gy or 0.5 Gy (placebo dose) were applied in five fractions to the lumbar spine including the facet joints. The pain was evaluated by means of the Oswestry-Disability-Score before, six weeks after therapy, and every three months during the follow-up (22.4 months on average). Drug therapy, physiotherapy, and physical treatment were continued.

RESULTS

According to the randomised distribution, 18 patients were treated with 5 Gy and 13 patients with 0.5 Gy. The Friedman-Test did not reveal any significant difference (p > 0.05) of the Oswestry-Disability-Index before and after therapy for both single questions and the sum of questions in both groups.

CONCLUSION

No significant decrease of the Disability Index after radiotherapy on the lumbar spine with 5 Gy could be demonstrated in the verum and placebo group. The authors do not recommend radiotherapy in cases of chronic low back pain. Individual successes have to be attributed to conservative treatment or placebo effects.

Metastatic epidural spinal cord compression

OBJECTIVES

To provide an overview on the presentation, diagnosis, and treatment of metastatic epidural spinal cord compression (MESCC).

DATA SOURCES

Published articles, book chapters, and research reports.

CONCLUSIONS

MESCC is a common oncologic emergency that requires prompt recognition and emergency treatment to relieve pain and preserve neurologic function. The signs and symptoms of MESCC are easily detected and can be integral assessment components of the nursing care of any patient with a solid tumor.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can have a dramatic impact on preventing neurologic complications caused by this oncologic metastatic problem. When neurologic compromise is not prevented or reversed, nurses also can provide expert care to patients and families in the rehabilitation phase of MESCC.