The Challenges of Research on Interventions for Low Back Pain
Authors: David J. Kennedy, Byron J. Schneider
Journal: Annals of Internal Medicine (2017)

Editorials18 April 2017The Challenges of Research on Interventions for Low Back PainDavid J. Kennedy, MD and Byron J. Schneider, MDDavid J. Kennedy, MDFrom Stanford University, Redwood City, California, and Vanderbilt University, Nashville, Tennessee.Search for more papers by this author and Byron J. Schneider, MDFrom Stanford University, Redwood City, California, and Vanderbilt University, Nashville, Tennessee.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-0556 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Nguyen and colleagues report a randomized trial of glucocorticoid intradiscal injection for patients with chronic low back pain associated with active discopathy (1). The authors are to be commended for avoiding a common error in studies of pain: the use of mean (or average) outcomes in populations in which pain does not have a normal distribution. Instead, the researchers followed the National Institutes of Health recommendations (2) and reported categorical outcomes to appropriately account for responders and nonresponders. With respect to the primary outcome, patients who received glucocorticoid intradiscal injection were more likely than those in the control group to ...References1. Nguyen C, Boutron I, Baron G, Sanchez K, Palazzo C, Benchimol R, et al. Intradiscal glucocorticoid injection for patients with chronic low back pain associated with active discopathy. A randomized trial. Ann Intern Med. 2017;166:547-56. doi:10.7326/M16-1700 LinkGoogle Scholar2. Deyo RA, Dworkin SF, Amtmann D, Andersson G, Borenstein D, Carragee E, et al. Report of the NIH Task Force on research standards for chronic low back pain. J Pain. 2014;15:569-85. [PMID: 24787228] doi:10.1016/j.jpain.2014.03.005 CrossrefMedlineGoogle Scholar3. Younes M, Neffati F, Touzi M, Hassen-Zrour S, Fendri Y, Béjia I, et al. Systemic effects of epidural and intra-articular glucocorticoid injections in diabetic and non-diabetic patients. Joint Bone Spine. 2007;74:472-6. [PMID: 17919959] CrossrefMedlineGoogle Scholar4. Ohtori S, Inoue G, Ito T, Koshi T, Ozawa T, Doya H, et al. Tumor necrosis factor-immunoreactive cells and PGP 9.5-immunoreactive nerve fibers in vertebral endplates of patients with discogenic low back pain and Modic type 1 or type 2 changes on MRI. Spine (Phila Pa 1976). 2006;31:1026-31. [PMID: 16641780] CrossrefMedlineGoogle Scholar5. Hagen KB, Tambs K, Bjerkedal T. A prospective cohort study of risk factors for disability retirement because of back pain in the general working population. Spine (Phila Pa 1976). 2002;27:1790-6. [PMID: 12195073] CrossrefMedlineGoogle Scholar6. Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, et al. Psychosocial risk factors for chronic low back pain in primary care—a systematic review. Fam Pract. 2011;28:12-21. [PMID: 20833704] doi:10.1093/fampra/cmq072 CrossrefMedlineGoogle Scholar7. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017. doi:10.7326/M16-2367 LinkGoogle Scholar8. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163-96. [PMID: 23245607] doi:10.1016/S0140-6736(12)61729-2 CrossrefMedlineGoogle Scholar9. Chou R, Hashimoto R, Friedly J, Fu R, Dana T, Sullivan S, et al. Pain Management Injection Therapies for Low Back Pain. Rockville: Agency for Healthcare Research and Quality; 2015. Accessed at www.ncbi.nlm.nih.gov/books/NBK285206 on 3 March 2017. Google Scholar10. Kennedy DJ, Levin J, Rosenquist R, Singh V, Smith C, Stojanovic MP, et al. Epidural steroid injections are safe and effective: multisociety letter in support of the safety and effectiveness of epidural steroid injections [Letter]. Pain Med. 2015;16:833-8. [PMID: 25586082] doi:10.1111/pme.12667 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Stanford University, Redwood City, California, and Vanderbilt University, Nashville, Tennessee.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0556.Corresponding Author: David J. Kennedy, MD, Department of Orthopaedic Surgery, Divisions of Physical Medicine & Rehabilitation and Spine, Stanford University, 450 Broadway Street, Redwood City, CA 94063; e-mail, [email protected]edu.Current Author Addresses: Dr. Kennedy: Department of Orthopaedic Surgery, Divisions of Physical Medicine & Rehabilitation and Spine, Stanford University, 450 Broadway Street, Redwood City, CA 94063.Dr. Schneider: Department of Physical Medicine and Rehabilitation, Vanderbilt University, 2201 Children's Way, Suite 1318, Nashville, TN 37067.This article was published at Annals.org on 21 March 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoIntradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy Christelle Nguyen , Isabelle Boutron , Gabriel Baron , Katherine Sanchez , Clémence Palazzo , Raphaël Benchimol , Guillaume Paris , Étienne James-Belin , Marie-Martine Lefèvre-Colau , Johann Beaudreuil , Jean-Denis Laredo , Anne Béra-Louville , Anne Cotten , Jean-Luc Drapé , Antoine Feydy , Philippe Ravaud , François Rannou , and Serge Poiraudeau Metrics Cited byThe effectiveness of intradiscal biologic treatments for discogenic low back pain: a systematic reviewThe challenges of precision medicine in chronic low back pain: Lessons learned from active discopathyLow back painShould Researchers and Journals Be More Cautious in Proposing Novel Pain Conditions? 18 April 2017Volume 166, Issue 8Page: 601-602KeywordsInflammationLower back painMagnetic resonance imagingPathology and laboratory medicinePopulation statisticsRandomized trialsRehabilitation medicineSpineSurgeryTreatment guidelines ePublished: 21 March 2017 Issue Published: 18 April 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. 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