A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Physical performance, pain, pain behavior and subjective disability in patients with subacute low back pain. Mini-intervention for subacute low back pain: a randomized controlled trial. A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Chronic unilateral low-back pain. Predictors of outcome of facet joint injections. Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain. Evaluation of a specific home exercise program for low back pain. A new approach to the treatment of chronic low back pain. Effectiveness of subcutaneous injection of sterile water to the lower back for pain relief in labor. Local and remote sustained trigger point therapy for exacerbations of chronic low back pain. A randomized, double-blind, controlled, multicenter trial. Injection of steroids and local anaesthetics as therapy for low-back pain. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain.
The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct in treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication. A randomized, assessor-blinded clinical trial was conducted.
                To investigate the relative effectiveness of three manual treatments and back school for patients with subacute low back pain.
                Literature comparing the relative effectiveness of specific therapies for low back pain is limited.
                Among the 5925 inquiries, 206 patients met the specific admission criteria, and 200 patients randomly received one of four treatments for 3 weeks: back school, joint manipulation, myofascial therapy, and combined joint manipulation and myofascial therapy. These patients received assessments at baseline, after 3 weeks of therapy, and 6 months after the completion of therapy. The primary outcomes were evaluated using visual analog pain scales and Roland-Morris activity scales.
                All four groups showed significant improvement in pain and activity scores after 3 weeks of care, but did not show further significant improvement at the 6-month follow-up assessment. No statistically significant between-group differences were found either at the 3-week or 6-month reassessments.
                For subacute low back pain, combined joint manipulation and myofascial therapy was as effective as joint manipulation or myofascial therapy alone. Additionally, back school was as effective as three manual treatments. Four treatment regimens for patients with specified combinations of low back pain and sciatica were evaluated. The largest group studied had low back pain with limited straight-leg raising (SLR) and in them the beneficial effect of manipulation in hastening pain relief was highly significant. In similar patients without limitation of SLR, the effect was of borderline significance. In all the other groups, treated patients also recovered more quickly than their controls. Traction, for patients with low back pain and sciatica, and epidural injections when a root palsy was present also produced some significant pain relief. The effect of sclerosants for back pain was less clear. Prospective randomized study to compare the efficacy of facet joint injection with lidocaine and facet joint injection with saline in two groups of patients with low back pain, with and without clinical criteria that were determined in a previous study to implicate the facet joint as the primary source of the pain.
                To assess the efficacy of single facet joint anesthesia versus placebo (saline injections) and to determine clinical criteria that are predictive of significant relief of LBP after injection.
                There is no syndrome that discriminates between lower back pain caused by facet joint and that caused by other structures. Single or double facet joint anesthesia, and single photon emission computed tomography are expensive and time-consuming procedures for selecting patients in controlled clinical trials with large populations.
                Results of a previous study showed that seven clinical characteristics were more frequent in patients who responded to facet joint anesthesia than in those who did not. In the current study, a group of 43 patients with lower back pain who met at least five criteria were compared with 37 patients who met fewer criteria. Patients randomly received injection of either lidocaine or saline into the lower facet joints. The result was considered positive if more than 75% pain relief was determined by visual analog scale. The patient, the radiologist, and the investigator were blinded. An analysis of variance was used to seek an interaction between clinical group effect and injection effect, and logistic regression analysis to select the best set of variables that would be predictive of minimum pain relief of 75% after the injection.
                There was a significant interaction between clinical group and injection effect (P = 0.003). In patients with back pain, lidocaine provided greater lower-back pain relief than saline (P = 0.01). Lidocaine also-provided greater pain relief in the back pain group than in the nonpain group (P = 0.02). The presence of five among seven variables (age greater than 65 years and pain that was not exacerbated by coughing, not worsened by hyperextension, not worsened by forward flexion, not worsened when rising from flexion, not worsened by extension-rotation, and well-relieved by recumbency), always including the last item, distinguished 92% of patients responding to lidocaine injection and 80% of those not responding in the lidocaine group.
                A set of five clinical characteristics can be used in randomized studies to select lower back pain that will be well relieved by facet joint anesthesia. These characteristics should not, however, be considered as definite diagnostic criteria of lower back pain originating from facet joints. The aim of this paper was to study the physical performance, pain, pain behavior and disability in patients with subacute low back pain (LBP). The patients were blue-collar workers and had been sick-listed for 8 weeks due to subacute low back pain. A total of 103 patients were randomized, 51 of them to the intervention group and the other to a control group. Recordings of physical performance and complaints of LBP were done before and after treatment in the intervention group. The proportion of patients with no complaints of LBP was significantly greater in the intervention group than in the control group at the one-year follow-up. The patients who intra-individually improved their physical performance also intra-individually decreased their complaints of LBP. The intra-individual improvements were suggested to be important for the individual return to work. Randomized controlled trial.
                To investigate the effectiveness and costs of a mini-intervention, provided in addition to the usual care, and the incremental effect of a work site visit for patients with subacute disabling low back pain.
                There is lack of data on cost-effectiveness of brief interventions for patients with prolonged low back pain.
                A total of 164 patients with subacute low back pain were randomized to a mini-intervention group (A), a work site visit group (B), or a usual care group (C). Groups A (n = 56) and B (n = 51) underwent one assessment by a physician plus a physiotherapist. Group B received a work site visit in addition. Group C served as controls (n = 57) and was treated in municipal primary health care. All patients received a leaflet on back pain. Pain, disability, specific and generic health-related quality of life, satisfaction with care, days on sick leave, and use and costs of health care consumption were measured at 3-, 6-, and 12-month follow-ups.
                During follow-up, fewer subjects had daily pain in Groups A and B than in Group C (Group A Group C, = 0.002; Group B Group C, = 0.030). In Group A, pain was less bothersome (Group A Group C, = 0.032) and interfered less with daily life (Group A Group C, = 0.040) than among controls. Average days on sick leave were 19 in Group A, 28 in Group B, and 41 in Group C (Group A Group C, = 0.019). Treatment satisfaction was better in the intervention groups than among the controls, and costs were lowest in the mini-intervention group.
                Mini-intervention reduced daily back pain symptoms and sickness absence, improved adaptation to pain and patient satisfaction among patients with subacute low back pain, without increasing health care costs. A work site visit did not increase effectiveness. To determine the clinical efficacy of sclerosing injections in patients with chronic low back pain.
                Randomized, double-blind, placebo-controlled trial of three, once weekly injections of dextrose-glycerine-phenol with lignocaine vs saline plus lignocaine in patients with mechanical back pain of more than 6 months' duration. All patient assessments were performed blind by an experienced physiotherapist. The injections to the ligaments of the L4-5 and L5-S1 lumbar motion segments were given by an orthopaedic physician experienced in the technique, blinded to the nature of the injection solution according to a standard protocol. Demographic and clinical data, the short-form McGill Pain Questionnaire, the modified Somatic Pain Questionnaire, the Zung Depression Inventory, Oswestry Disability Scale and the modified Schober method of measuring spinal flexion were undertaken at 0, 1, 3 and 6 months.
                Seventy-four patients [mean (S.D.) age 45(11) yr, female:male ratio 1:1, median pain duration >10 yr] were recruited and there were no drop-outs over the study period. There were no statistically significant differences in patient characteristics between the placebo and treatment groups at baseline or for any measure at follow-up.
                Three, weekly sclerosant injections alone may not be effective treatment in many patients with undifferentiated chronic back pain. Patient selection and combination with other treatment modalities may be factors in determining treatment success. The effectiveness of massage therapy for low-back pain has not been documented. This randomized controlled trial compared comprehensive massage therapy (soft-tissue manipulation, remedial exercise and posture education), 2 components of massage therapy and placebo in the treatment of subacute (between 1 week and 8 months) low-back pain.
                Subjects with subacute low-back pain were randomly assigned to 1 of 4 groups: comprehensive massage therapy (n = 25), soft-tissue manipulation only (n = 25), remedial exercise with posture education only (n = 22) or a placebo of sham laser therapy (n = 26). Each subject received 6 treatments within approximately 1 month. Outcome measures obtained at baseline, after treatment and at 1-month follow-up consisted of the Roland Disability Questionnaire (RDQ), the McGill Pain Questionnaire (PPI and PRI), the State Anxiety Index and the Modified Schober test (lumbar range of motion).
                Of the 107 subjects who passed screening, 98 (92%) completed post-treatment tests and 91 (85%) completed follow-up tests. Statistically significant differences were noted after treatment and at follow-up. The comprehensive massage therapy group had improved function (mean RDQ score 1.54 v. 2.86-6.5, p < 0.001), less intense pain (mean PPI score 0.42 v. 1.18-1.75, p < 0.001) and a decrease in the quality of pain (mean PRI score 2.29 v. 4.55-7.71, p = 0.006) compared with the other 3 groups. Clinical significance was evident for the comprehensive massage therapy group and the soft-tissue manipulation group on the measure of function. At 1-month follow-up 63% of subjects in the comprehensive massage therapy group reported no pain as compared with 27% of the soft-tissue manipulation group, 14% of the remedial exercise group and 0% of the sham laser therapy group.
                Patients with subacute low-back pain were shown to benefit from massage therapy, as regulated by the College of Massage Therapists of Ontario and delivered by experienced massage therapists. One hundred nine patients with chronic (3-36 months; mean, 13.4 months) unilateral low-back pain and no signs of sciatica were subjected to facet joint injection, randomized in three therapy groups: cortisone and local anesthetic injected intra-articularly, the same mixture injected pericapsularly, and physiologic sodium hydrochloride injected intra-articularly into two facet joints. To evaluate the results, three outcome variables were formed: work, subjective, and disability outcome. The inappropriate signs (IAS) recorded before injections had the best predictability for a good outcome. The mode of injection or duration of symptoms had no significance as a predictor. It was concluded that the outcome after facet joint injection depends on the patient's biopsychosocial chances of self-facilitated improvement. If abnormal illness behavior and distress are found, it helps to estimate the response for treatment and to choose a realistic method of treatment. Eighty-six patients with refractory chronic low back pain were randomly assigned to receive either facet joint injection or facet nerve block, using local anaesthetic and steroid. There was no significant difference in the immediate response. The duration of response after facet joint injection was marginally longer than after facet nerve block (P less than 0.05 1 month after infiltration), but for both groups the response was usually short-lived; by 3 months only 2 patients continued to report complete pain relief. Patients who had complained of pain for more than 7 years were more likely to report good or excellent pain relief than those with a shorter history (P less than 0.005), but no other clinical feature was of value in predicting the response to infiltration. Facet joint injections and facet nerve blocks may be of equal value as diagnostic tests, but neither is a satisfactory treatment for chronic back pain. The prescription of exercise as a conservative treatment for lumbar pain is frequent and seems effective for the chronic cases of nonspecific low back pain. However, there is no evidence favoring one type of exercise over another. Often, exercise programs are prescribed without adequate evaluation of the individual characteristics like posture, muscular force, and extensibility. Patients with totally different causes of low back pain will often be given the same type of exercises.
                Our objective was to compare the effectiveness of 2 home exercise programs in decreasing disability and pain related to subacute and chronic nonspecific low back pain. To do so we compared a specific (individualized) exercise program with a program of commonly prescribed exercises for low back pain.
                In a control group study, 20 patients with chronic or subacute nonspecific low back pain participated after giving their informed consent. All subjects were evaluated (physical evaluation of lumbar and pelvic muscles [1] force and [2] extensibility, [3] trunk range of motion) and then divided in 2 groups: 10 patients received specific exercises (experimental group) based on their evaluation, and 10 patients received a commonly prescribed exercise program for low back pain (control group). Six weeks later a second physical evaluation was conducted. Pain (visual analog pain scale) and disability (modified Oswestry) questionnaires were also completed by each subject at both evaluations.
                This was a randomized experimental study.
                Both groups had similar age, weight, and sex characteristics. The experimental group showed significant improvements for some components targeted by the program. The control group significantly had improvement of some physical characteristics not related to their initial deficits. Even if both groups showed some improvements in muscular force and extensibility, only the members of the group who received specific exercises significantly reduced their level of pain and disability. Both groups showed a similar rate of participation in the program.
                The results of this study suggest that applying a specific physical evaluation and exercise prescription is an appropriate treatment for people having subacute or chronic nonspecific pain. Thus clinicians should prescribe exercise programs based on individual muscular deficits rather than most commonly prescribed exercise programs. 81 patients with chronic low back pain (average duration 10 years) were randomised to two treatment groups. 40 received an empirically devised regimen of forceful spinal manipulation and injections of a dextrose-glycerine-phenol ("proliferant") solution into soft-tissue structures, as part of a programme to decrease pain and disability. The other 41 patients received parallel treatment in which the main differences were less extensive initial local anaesthesia and manipulation, and substitution of saline for proliferant. Neither patients nor assessors knew which treatment had been given. When assessed by disability scores the experimental group had greater improvement than the control group at one (p less than 0.001), three (p less than 0.004), and six (p less than 0.001) months from the end of treatment; at six months an improvement of more than 50% was recorded in 35 of the experimental group versus 16 of the control group and the numbers free from disability were 15 and 4, respectively (p less than 0.003). Visual analogue pain scores and pain diagrams likewise showed significant advantages for the experimental regimen. The analgesic efficacy of subcutaneous injection of sterile water compared to isotonic saline was investigated in a randomized, controlled study on a total of 100 women in the active phase of labor and who complained of low back pain. Pain perception was rated on a numerical rating scale before and at 10 and 45 minutes after the injection. The initial pain score was the same in both groups and pain relief was expressed by both groups irrespective of the solution injected, but the sterile water group had significantly higher relief scores compared to those receiving saline. This was not influenced by maternal age, parity, education, body mass index, cervical dilatation at intervention or fetal size, suggesting that subcutaneous injection of sterile water to the lower back provides relief from back pain during labor. A randomized, double-blind, controlled, multicenter trial was conducted.
                To assess the efficacy of neuroreflexotherapy in the management of low back pain.
                Neuroreflexotherapy consists of temporary implantation of epidermal devices in trigger points in the back and referred tender points in the ear.
                The rheumatology and rehabilitation departments of three teaching hospitals in Madrid recruited 78 patients with chronic low back pain. These patients were randomly assigned to the control group (37 patients) or to the treatment group (41 patients). Patients in the treatment group underwent one neuroreflexotherapeutic intervention. The control group received sham treatment consisting of placement of the same number of epidermal devices within a 5-cm radius of the target zones. Patients from both groups were allowed to continue drug treatment as previously prescribed. The use of medications during the trial was recorded.
                Patients underwent clinical evaluations on three occasions: within 5 minutes before intervention, within 5 minutes after intervention, and 45 days later. The preintervention assessment was carried out by the physician from each hospital department who included the patient in the study. Each of the two follow-up assessments were carried out independently by two of three physicians who had no connection with the research team. Patients in the treatment group showed immediate lessening of pain compared with the results in patients in the control group. The pain relief was clinically relevant and statistically significant, and it persisted up to the end of the trial.
                Neuroreflexotherapy intervention seems to be a simple and effective treatment for rapid amelioration of pain episodes in patients with chronic low back pain. At this time, the duration of pain relief beyond 45 days has not been evaluated. Thirty patients with low-back pain of at least one month's duration were included in a double-blind controlled study with third-party administration and treated with either methylprednisolone acetate mixed with lignocaine or isotonic saline, injected at the site of the iliolumbar ligament. The treatment was evaluated by a visual analogue scale, range of spinal flexion ad modum Wright & Moll and of the patients' self-assessments. In the methylprednisolone group, significant decreases in pain score and in patients' self-assessments were found. The range of spinal flexion did not undergo any significant change. No significant changes were found in the control group. No side effects were observed during the study. A randomized prospective trial of manipulation, massage, corset and transcutaneous muscle stimulation (TMS) was conducted in patients with subacute low back pain.
                The authors determined the relative efficacy of chiropractic treatment to massage, corset, and TMS.
                Although all of these treatments are used for subacute low back pain treatment, there have been few comparative trials using objective outcome criteria. Patients were enrolled for a period of 3 weeks. They were evaluated once a week by questionnaires, visual analog scale, range of motion, maximum voluntary extension effort, straight leg raising and Biering-Sorensen fatigue test. The dropout rate was highest in the muscle stimulation and corset groups and lowest in the manipulation group. Rates of full compliance did not differ significantly across treatments. A measure of patient confidence was greatest in the manipulation group.
                After 3 weeks, the manipulation group scored the greatest improvements in flexion and pain while the massage group had the best extension effort and fatigue time, and the muscle stimulation group the best extension.
                None of the changes in physical outcome measures (range of motion, fatigue, strength or pain) were significantly different between any of the groups.
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.