Transcript No Slide Title

Procedural Interventions And Chronic Low Back Pain: Changes Over One Year
Noelle Fernandez, Sandra Burge Ph.D, K. Ashok Kumar MD
The University of Texas Health Science Center at San Antonio
INTRODUCTION
Chronic low back pain (CLBP) often leaves patients trapped in a
vicious circle of pain, disability and failed treatments.1 It is the leading
cause of disability in the industrialized world.2 In recent years, studies
have examined treatments such as physical therapy, injections, pain
clinic intervention, and surgical intervention. However, no single
medical treatment method has proven effective for alleviating
CLBP.1,2,3 Some research suggests that lumbar fusion in patients with
severe CLBP can diminish pain and decrease disability more
efficiently than commonly used nonsurgical treatment4, while other
evidence suggests that cognitive intervention and exercises are
equally effective. One study showed that despite surgical intervention,
87% of patients reported that they continued to have pain 1–8 years
after surgery.1 There is moderate evidence for success using
transforaminal epidural steroid injections, lumbar percutaneous
adhesiolysis and spinal endoscopy for painful lumbar radiculopathy.2
Physical therapy and different forms of exercise can give satisfactory
results, at least in the short term.4 While many studies focus on
comparing types of treatment, there is little evidence to suggest
whether medical procedures have an advantage to alleviating CLBP
when compared to no procedural treatment. This study will analyze
the effectiveness of procedural medical treatments when compared to
nonuse of procedural medical treatments, in alleviating pain,
increasing physical functioning, and decreasing depression symptoms
in patients with CLBP.
Figures 1-4
This sample included 137 patients with complete surveys and chart
reviews; 74% were women, 26% were men, half were White, and their
average age was 56.2 years. A total of 51 used some treatment
procedure over the past 12 months. Comparing the 51 procedure-users
to nonusers, we found no significant differences in changes in pain,
physical functioning, or depression over one year. Considering
treatments individually, some trends were apparent (Figures 1-4).
Users of injections (N=17) or pain clinic (N=22) had worse pain one
year later, while nonusers had improved pain scores. Users of physical
therapy (N=24) reported poorer physical functioning, while nonusers
reported improved functioning one year later. Finally, users of
chiropractors/adjustments (N=5) had significantly improved depression
one year later. Users and nonusers of surgical interventions in the past
year showed no group differences in pain, function, or depression. A
cross-sectional analysis of 2009 data showed similar findings. Patients
who used injections or pain clinic reported worse pain than nonusers.
Patients who used a chiropractor in the past year reported less
depression. No other significant differences were noted.
CONCLUSIONS
Patients who used procedural treatments showed no evidence of
improved pain or physical functioning over one year. Perhaps these
patients experienced worse pain or function and sought out other
interventions. However, these treatments did not seem to be
successful in alleviating pain or functioning. On average, patients did
not get better. These findings are consistent with other evidence
suggesting there is no treatment proven to alleviate chronic low back
pain.2 It is possible that the failure of treatments is related to nonadherence to treatment plans, severity of CLBP, or an increased state
of depression. Physicians and researchers will need to continue to
study treatment options for patients with chronic low back pain in
order to develop an effective treatment.
METHODS
In 2009, student research assistants sought one-year followup data
from 213 patients enrolled in 2008. At enrollment, these patients had
low back pain for 3 months or longer; investigators excluded
pregnant women and patients with cancer. Students completed
medical records of 204 patients (96% followup), and surveys of 137
patients (64% followup).
Information from medical records included causes of low back
pain, treatments for pain, comorbidities, and BMI. A patient survey
addressed demographic characteristics, pain duration, frequency and
severity, physical functioning and general health, anxiety, depression,
substance abuse, and risk for opioid misuse.
This analysis calculated changes in pain, functioning and
depression over one year, and determined whether treatment use
(chiropractor, injections, pain clinic, physical therapy, or surgery) in
the past year was associated with improvements.
RESULTS
REFERENCES
1. Bentsen SB et al. Journal of Clinical Nursing 2008; 17(7B):153-9.
Acknowledgements: This study was conducted In the Residency Research
Network of Texas (RRNeT) with support from the Texas Academy of Family
Physicians, the South Texas Area Health Education Center, and the Dean’s
Office, School of Medicine, UTHSCSA.
2. Cahana A et al. Expert Review of Neurotherapeutics 2004; 4(3):479-90.
3. Hildebrandt J et al. Spine 1997; 22(9):990-1001.
4. Fritzell P et al. Spine 2001; 26(23):2521-34.
5. Brox JI et al. Spine 2003; 28(17):1913-21.