Horses for courses: or how to choose the best person to get spinal injection treatment


ResearchBlogging.org

There are many different ways to report on the findings of a clinical study: this one intrigued me because it looks at who does well after radiofrequency and injection treatments for low back pain.
In a post hoc study of 161 people receiving these treatments for back pain and sciatica, subsequently treated in an open prospective follow-up period, those with positive psychosocial features did well, while those who were psychologically ‘more vulnerable’ did not do as well.

The study is interesting for a couple of reasons – it was part of a double-blind study of radiofrequency neurotomy (RNF), in which patients received sham RF lesioning (no current was applied to the nerve, although anaesthetic was still provided). The major finding of this study was that ‘the vast majority of patients failed to respond according to the primary combined outcome measure, comprising VAS, physical activity scores, and analgesics scores.’ The authors found, however, that ‘in each trial, a comparable statistically significant VAS reduction was found in both RF and control lesion groups. It was concluded that in these selected groups of patients, both RF and sham (local anesthetic injection) treatment should be regarded as about equally effective.’

For the 9 months following this first treatment, these patients were provided with follow-up – and ‘treated as found necessary on clinical grounds in an open prospective followup period of 9 months. Additional treatment consisted of a variable combination of RF and/or steroid injection treatments.’ During this time, however, these patients didn’t receive any other treatment, whether surgical or cognitive behavioural.

A comprehensive battery of questionnaires were completed by the participants, and the researchers used the responses to identify five separate groups of patients: “psychologically negative”, or people who didn’t do well and experienced high interference, reduced control, low mood, high anxiety and so on; “adaptive manager”, or people who coped pretty well and regained or remained active; “inflexible qualities”; presenting as resigned, rigid, and feeling wronged; “supporting partner”, those with a rewarding, supportive and helpful partner; and “strong ego”, or those with high self-esteem, dominance, and high social adequacy.

The findings? Well, those in the ‘adaptive manager’ group did well at three months, reporting a 50% reduction in pain – and a similar finding at the long-term followup point also.
Those who were ‘psychologically negative’ didn’t do as well, especially at the long term followup.
The authors summarise by saying ‘patients characterized by reduced pain and interference levels, reasonable physical activities levels, positive expectations, and reasonable physical and social functioning, perform more favorably on these interventions.’

Although they don’t suggest that people who lack these resilient characteristics shouldn’t get RF and injection treatments, I’d suggest that these people will also need a cognitive behavioural approach to effectively manage the psychosocial components of their disability.

The real question is: do clinicians who treat patients with these interventions routinely assess the psychosocial profiles of their patients? Or do they simply follow the biomedical model and manage them accordingly?

van Wijk, R., Geurts, J., Lousberg, R., Wynne, H., Hammink, E., Knape, J., & Groen, G. (2008). Psychological Predictors of Substantial Pain Reduction after Minimally Invasive Radiofrequency and Injection Treatments for Chronic Low Back Pain Pain Medicine, 9 (2), 212-221 DOI: 10.1111/j.1526-4637.2007.00367.x

6 comments

  1. From seeing people who have had this done, my first advice would be’get a second opinion about whether the procedure is appropriate’.

    Having seen a number of people with sciatica who have forked over thousands for facet-joint injections, the only person I refer to now is our local chronic pain specialist, who I know will treat appropriately and ethically. The biggest problem in this field is the number of clinics offering ‘spinal injections’ without any monitoring or oversight by senior clinicians.

    NB for the non-docs among you, sciatica is not caused by facet joint inflammation.

    1. Thanks for your comment Fi. I think it’s really important to (1) have good selection criteria for who will benefit from any procedure (2) an effective way to monitor outcomes and (3) a focus on increased activity and function rather than reduced pain. I also do wonder whether repeating the procedure every few months is especially effective – it’s both time consuming and people run the risk of becoming ‘a patient’ rather than a person who just happens to have chronic pain.
      The next study I’d like to see is a group of positive copers who are randomised into receiving treatments vs a control – I wonder whether people who are generally positive copers need the injections to get better, or whether they’ll do just as well without.

  2. This is an area where most people are really out of their depth – they don’t know anything about spinal anatomy or pathology, much less how it relates to their condition. There’s way too much room for charlatans of both the medical and woo varieties to bamboozle them into handing over large sums of money.

    The natural history of back pain is variable and there can be enormous psychological overlay -the latter alowing a significant placebo effect from treatment, as demonstrated here. Then you get into the murky waters of ‘well, it worked, even if it was placebo, therefore we should continue to provide the treatment’, which makes me, as a physician, extremely uncomfortable.

    This is also an extremely difficult area to do good research – the patients are a heterogenous group, in underlying pathology, premorbid personality, coping skills and also in what the pathology has cost them personally. I liken it to a group I was part of for the support of depression – two years later all those who were the primary wage earners had returned to full time work, whereas those whose family paid their rent, food bills etc or who were on government support had either not returned to work or were working a maximum of two days a week. I don’t know how you control for all these other factors to establish a treatment effect without having enormous groups to study.

    1. You have a great grasp on the issues! I think all pain has a psychosocial component to it – and risk factors for chronicity are almost entirely psychosocial. We know that distressed people present for more treatment than undistressed, and yet from this study, it seems they don’t respond well – but I don’t know many doctors who would be able to say ‘what you need is good management of your distress’! Many will be quite comfortable at least for a good while to continue with ineffective monotherapy whether it’s injections, medications or hands-on therapy. Studying the response to therapy is complex, because placebo or ‘meaning response’ as Dan Moerman puts it, cannot be eliminated in any health situation where there are people interacting. It suggests to me that all health providers need to learn much more about effective assessment and communication to make sure a short-term consequence doesn’t have negative effects in the long-term.

  3. I would love to take care of people’s psychosocial issues as well as their physical ones, but despite people constantly complaining that doctors are too focused on the physical, the moment you start asking about symptoms of depression, coping at work etc they almost inevitably stiffen and say something along the lines of ‘are you saying it’s all in my HEAD?’

    Not all people are like this but it’s a real bind that physicians are caught in. Other prviders – nurses, physios etc, can ask these questions, but the moment a doctor does it, they’re ‘not taking me seriously’ ‘implying I’m mad’.

    Believe me, when you’ve had a couple of consultations blow up in your face like this, you get very careful about asking these questions. And I see a lot of patients with depression, alcohol abuse etc, so it’s not as if I don’t have these discussions on a regular basis.

    Chronic pain patients are often the most resistant to understanding the whole psychosocial/pain interface.

    1. Now that’s an excellent observation. I’ll post about this I think, because it is one of the major barriers to good people like you being able to provide the most appropriate management to individuals with chronic pain. I think one of the reasons people with chronic pain respond so antagonistically is that they are fearful that they are being judged for having their pain, and that they wonder themselves whether they are really the authors of their own misery. It’s also about how our society views pain – as either body or mind, not both. Some public health education would be great!
      In the meantime, the fact that you can identify psychosocial factors is a great first step – and maybe referring the person to someone who is viewed by these patients as ‘acceptable’ to ask the questions is your best step. Then a conference with that provider and the person with pain might help the management plan become fully integrated. Thanks for your enthusiasm for this topic – I hope to hear from you again soon!

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