ABSTRACT
Objective: This study investigated whether patients with Modic changes (MC) of types I, I/II, and II would respond to an anti-inflammatory-based, stepped care treatment with three treatment steps: first, oral administration of NSAIDs, 2 × 200 mg celecoxib daily for two weeks; second, an intradiscal steroid injection (ID) with dexamethasone and cefazolin; and third, oral treatment with antibiotics (AB), 3 × 1 g amoxicillin daily for 100 days. Design: This was an observational clinical study based on analyses of categorical data of patient-reported outcome measurements. Subjects: Subjects were consecutive patients with chronic low back pain (CLBP), diagnosed by assessment of anamnestic signs of inflammation; a pain score ≥6 on the Numeric Pain Rating Scale (NPRS); a mechanical assessment; MC I, I/II, or II based on MRI; and lack of response to conservative treatment. Methods: From January 1, 2015, to December 31, 2021, 833 eligible patients were selected for the stepped care treatment. A total of 332 patients completed requested follow-up questionnaires at baseline and 12 months (optional at 3 and 6 months). Primary outcomes were pain (at least 50 % pain relief) and/or a minimum of 40 % improvement in functionality as measured by the Roland Morris Disability Questionnaire (RMDQ) or the Oswestry Disability Questionnaire (ODI). Secondary outcome measures were use of pain medication and return to work. Results: At 1 year of follow-up, 179 (53.6 %) of 332 patients reported improvement according to the responder criteria. Of the 138 patients that had received only NSAIDs, 88 (63.8 %) had improved. In addition, 50 (56.8 %) of the 183 patients that had received ID had improved, and 41 (38.7 %) of the 106 patients treated with AB had improved. None of the patients reported complications. 12.0 % of patients using AB stopped preterm due to undesirable side effects. Conclusion: Treatment with a stepped care model for inflammatory pain produced clinically relevant, positive reported outcomes on pain and/or function. Our stepped care model appears to be a useful, safe, and cost-saving treatment option that is easily reproducible. Further studies, including randomized controlled trials and analyses of subgroups, may help to develop a more patient-tailored approach and further avoidance of less-effective treatments and costs.
ABSTRACT
STUDY DESIGN: Prospective cohort, test-retest design. BACKGROUND: Directional preference (DP) with centralization (CEN) and DP without CEN are common pain-pattern responses assessed by Mechanical Diagnosis and Therapy (MDT). Although there is evidence that MDT can reduce pain and disability in the short term by treating the patient with direction-specific exercises concordant with the patient's DP, the mechanism responsible for this is unclear. OBJECTIVE: To determine whether clinical signs of impaired spinal control improve immediately after eliciting a DP-with-CEN response or a DP-without-CEN response in patients with nonspecific low back pain. METHODS: Participants underwent a standardized MDT assessment and were classified into the following pain-pattern subgroups: DP with CEN, DP without CEN, or no DP. Clinical signs of impaired spinal control were assessed pre-MDT assessment and post-MDT assessment by an independent examiner. Four spinal control tests were conducted: aberrant lumbar movements while bending forward, the active straight leg raise (ASLR) test, the Trendelenburg test, and the prone instability test. Differences in spinal control pre-MDT assessment and post-MDT assessment were calculated for the 3 pain-pattern subgroups and compared with chi-square tests. We hypothesized that a larger proportion of patients in the DP-with-CEN subgroup would exhibit improved spinal control than patients categorized as DP without CEN or no DP. RESULTS: Of 114 patients recruited, 51 patients (44.7%) were categorized as DP with CEN, 23 (20.2%) as DP without CEN, and 40 (35.1%) as no DP. Before MDT assessment, between 28.9% (Trendelenburg test) and 63.7% (ASLR test) of patients showed impaired spinal control. After MDT assessment, a larger proportion of patients in the DP-with-CEN subgroup (43%) showed improvement than those in the no-DP subgroup (7%) on aberrant lumbar movements (P = .02). Likewise, more patients in the DP-with-CEN subgroup (50%) improved on the ASLR test than those in the no-DP subgroup (8%, P<.01) or the DP-without-CEN subgroup (7%, P = .01). Changes in Trendelenburg test and prone instability test outcomes did not reach statistical significance. CONCLUSION: Immediately following MDT assessment, a larger proportion of patients with a DP-with-CEN pain pattern showed improvement in clinical signs of spinal control compared to patients with a DP-without-CEN or no-DP pain pattern. The current study was registered in the Dutch trial registry at http://www.trialregister.nl/trialreg/index.asp (NTR4246). LEVEL OF EVIDENCE: Therapy, level 2b.