Clinical Consult

In Baton Rouge, there are "pain clinics" popping up everywhere and the docs are injecting anything that moves. The internists and primary care MDs are getting marketed hard by the pain docs to send musculoskeletal patients to them.  Of course there is no manual therapy or therapeutic exercise associated with them. Is anyone aware of studies comparing manual physical therapy and/or exercise to epidural steroid injections?

Seth Kaplan PT, OCS, MHA
President and CEO
BRPT-LAKE
Rehabilitation Centers, L.L.C.

Comments

[Steve Jorgensen]

What patient population is being targeted with these clinics? Are they just cases of, say, non-specific low back pain that are not in the chronic phase, or are they more chronic pain patients? I am not aware of any studies comparing OMT with epidural steroid, although I would usually assume the latter approach would be for patients who have not had success with non-invasive rehab approaches. Here in Victoria BC, a "Pain Clinic" has recently been established, and it seems that it is very doc-driven. From my understanding, they are using not only steroid injections, but also an approach that cauterises specific nerves (presumably the dorsal rami of the nerve roots?) in cases of intractable chronic pain. I have a patient at the moment who in undergoing assessement at this clinic. Assessment involves freezing of specific areas and his saying whether the pain is abolished, and then that is used as a guide to where/what to toast.

Steve Jorgensen

[Sandra Do, PT]

I am also not aware of a specific study comparing epidurals to manual therapy with LBP, however, another comon procedure in these clinics is the facet injection. I just came across a reveiw of the research on this topic by Bogduk published in Pain Medicine, 2005. Essentially there is little to support this form of intervention for LBP.

Pain Medicine
Volume 6 Page 287 - July 2005
doi:10.1111/j.1526-4637.2005.00048.x
Volume 6 Issue 4

A Narrative Review of Intra-Articular Corticosteroid Injections for Low Back Pain
Nikolai Bogduk, MD, PhD, DSc*

ABSTRACT
Objective. To summarize and to analyze the available literature on the efficacy of intra-articular injections of corticosteroids for low back pain.
Design. Publications, in English, French, and German, were obtained that reported the proportions of patients who obtained complete relief of pain following intra-articular steroids, and that provided any form of follow-up. These publications were analyzed to determine the rationale, indications, and outcomes of the treatment.
Results. The only rationale for intra-articular steroids appears to be the expectation that they should work. The most commonly used indication has been back pain, for which no specific diagnosis has been made. When the results of observational studies are pooled, they paint a picture of impressive immediate responses, but a rapid decay of outcomes by three and six months. Initial responses, however, are dissonant with the literature from controlled studies of the prevalence of lumbar zygapophysial joint pain. Moreover, controlled trials have shown that there is no attributable effect to the injection of steroids.
Conclusion. The apparent efficacy of lumbar intra-articular steroids is no greater than that of a sham injection. There is no justification for the continued use of this intervention. Better outcomes can be achieved with deliberate placebo therapy.

[Jason Silvernail]

Great citation, Sandra!
I love this line: "The only rationale for intra-articular steroids appears to be the expectation that they should work."
I think even a brief read of the relevant neuroscience literature reduces that expectation quite a bit.

I think this will be much like the proliferation of fusion surgery which got out way ahead of the evidence and enjoyed lots of popularity (more so with surgeons than with patients) before we finally started to realize it doesn't work that well. I think COX-2 inhibitors are probably another example of popularity getting ahead of evidence. I would venture to guess these injections and denervations will eventually come out like lumbar fusion - they won't work that well for pain, but they sure will reimburse well, won't they?

I think for patients presenting with pain of mechanical origin (most or our caseload), the use of local steroid injection seemingly targeted at some type of inflammatory process doesn't make sense.

I think the radiofrequency denervation of dorsal roots may be something different, but it's much like what I tell my patients about their pain - the goal is not to elminate the symptom, but to address the cause of the stimulus. Address the need state in the body. If your stomach was growling, you wouldn't think first of cutting it out, you'd just get something to eat.

I wonder why offering our patients something to eat is such a rare thing. I also wonder if our own record of management of painful problems hasn't contributed to this situation.
Thoughts?

J

[Steve Young]

Sandra,

Great reference. I do, however, believe that there may be some efficacy to the radiofrequency neurotomy for patients with chronic spinal pain - although this is far from being conclusive:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16886020&query_hl=1&itool=pubmed_docsum

Jason, your comment on putting new treatment ahead of the evidence is well stated.

Steve

[Steve Jorgensen]

Thanks for that reference, Steve. Here is another one that I have found. This looks at cervical and cervicobrachial pain as well as LBP (facet and discogenic). The results are not quite so positive as in the study you have cited. Could be that the reviewers only considered RCT's?
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=12535508

As with any procedure, the selection of patients who are suited to it is no doubt essential. The less the psychosocial baggage the better, where recovery from disability is concerned, and I wouldn't mind betting that the patients who did well were on the lower end of that scale. How about a comparison trial between patients receiving this procedure vs patients receiving the procedure plus psychosocial intervention?

Steve.

[Dawn]

I'm trying to remember my attitude "before" my injuries/pain; I probably sounded much like yourselves. Try to remember your main focus - the patient. If all the different disciplines would work together, instead of worrying that someone else might get a piece of the pie, your patient would actually benefit. When you are disabled at some point (which will happen between now and death, it just depends for how long) you may not be content to just "live" with your pain. So I feel pain clinics do offer another tool in My tool box to help live a better life.