Background
Methods
Types of studies
Types of participants
Types of interventions
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Oral or topical medications.
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Corticosteroid injections other than into the facet joints.
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Physical therapies including exercise (supervised or unsupervised), acupuncture, and manual treatments (osteopathy and chiropractic).
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Psychological interventions including cognitive-behavioural therapy (CBT).
Types of outcome measures
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Symptom relief based on pain.
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Back specific functional status (disability).
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Pain—measured by Visual Analogue Scale (VAS), Numerical Rating Scale (NRS) or McGill pain questionnaire or similar.
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Disability—measured by Oswestry disability index (ODI), Roland–Morris disability questionnaire (RMDQ), Million VAS disability score or Sickness Impact Profile (SIP) or similar.
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Adverse events.
Search methods for identification (electronic/other resources)
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Medline
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EMBASE
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CINAHL
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CENTRAL
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Index to chiropractic literature
Data collection and analyses
Selection of studies
Data extraction and management
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Study characteristics (aims of the study, study design, randomisation).
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Population characteristics—(patient population source or setting, study inclusion and exclusion criteria, duration of low back pain, diagnostic criteria, age, sex, country).
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Intervention characteristics—(description and types of corticosteroid, dose).
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Comparator characteristics—(description of comparator, duration, frequency).
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Outcome data—(pain intensity and disability at short term, medium term and long term).
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Number of participants assessed, number of dropouts.
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Statistical methods and results.
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Adverse events.
Assessment of risk of bias in included studies
Data synthesis
Results
Included studies
No. | References and country | Participants | Inclusion/exclusion criteria | Intervention | Control |
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1. | Lilius et al. [26] Finland | 61 women and 48 men (mean age 44 years, 19–64) IAC group, n = 28 PCC group, n = 39 IAS group (control) (n = 42) | Inclusion criteria: A negative straight leg raising test No improvement with previous analgesic and physiotherapy treatment | Intra-articular cortisone (IAC) group: 6 ml (30 mg) bupivacaine hydrochloride (Marcain) mixed with 2 ml (80 mg) methyl-prednisolone acetate was injected into each of the two facet joints Peri-capsular cortisone (PCC) group: 6 ml (30 mg) bupivacaine hydrochloride (Marcain) mixed with 2 ml (80 mg) methyl-prednisolone acetate was injected peri-capsularly around the two facet joints | Intra-articular saline (IAS) group: 8 ml of physiological saline was injected into the two facet joints |
2. | Carette et al. [27] Canada | Intervention n = 49 51 % male, mean age 42.5 years Control n = 48 58 % male, mean age 43 years | Inclusion criteria: Aged between 18 and 65 Had to have had a first or recurrent episode of low back pain, buttock pain or both for at least 6 months Pain could be intermittent or constant, unilateral or bilateral, radiating or non-radiating but had to be present Normal neurological examination results Exclusion criteria: Back pain without a mechanical cause (e.g. tumour, infection, spondylitis) Previous injections into facet joints or low back surgery Pregnancy Known allergy to local anaesthetic or radiological contrast agent Blood coagulation disorder | 20 mg (1 ml) methyl-prednisolone acetate in combination with 1 ml of isotonic saline | 2 ml isotonic saline |
3. | Mayer et al. [28] USA | Intervention n = 36 75 % male, mean age 43.4 (±8.5) years Control n = 34 67.6 % male, mean age 46.2 (±10.5) years | Inclusion criterion: Segmental rigidity on examination with maximum of 3 segments included (either unilateral or bilateral rigidity) Exclusion criteria: Declined injection as a treatment option More than 3 levels of segmental rigidity Failure to achieve insurance preauthorisation | Exercise plus 1 ml 2 % lidocaine, 1 ml 0.5 % bupivacaine including 1 ml of a depot corticosteroid preparation (unspecific) | Exercise only—twice a week in a facility and advised to do home stretching programme. Use facility 4–6 h, beginning once–twice a week and then ending final week with daily exercise |
4. | Celik et al. [29] Turkey | Intervention n = 40 13 males (32.5 %), 27 females (67.5 %) mean age 37.6 (±9.2) years Control n = 40 14 male (35 %), 26 females (65 %) mean age 34.9 (±8.5) years | Inclusion criteria: Aged 20–60, male or female The patients suffered low back pain, but no extensions of pain to the legs Patient pain was exacerbated with hyperextension and alleviated by flexion Patient had maximally a 4-month history of pain Exclusion criteria: Patients with lumbar pathologies diagnosed by radiology such as lumbar herniated disc disease, spondylolisthesis, narrow spinal canal, scoliosis or other spinal deformities, fracture, mass lesions, etc. Patients with a history of major or radiologically demonstrable lumbar trauma Patients with radiologically demonstrated lumbar facet arthropathy, black disc or MODIC changes Patients with pathologies diagnosed by EMG such as mononeuropathies, polyneuropathies, and compression neuropathies or have a finding for root or nerve compression Patients with a history of previous lumbar surgery Patients with a metabolic bone disease Patients with a history of rheumatoid disease Patients with a serious systematic disease such as uncontrolled diabetes mellitus, chronic kidney failure, hypertension, chronic obstructive pulmonary disease, cardiac failure Patients with a neoplastic disease Patients with a psychiatric disease Patients have a sciatalgia, radiculopathy, neurological deficits Patients with an epileptic or severe neurological disease Child bearing women and suspicion of pregnancy Patients with a skin lesion on the lumbar area or systematic dermatological disease Patients with a venous failure on their legs Patients with a previously diagnosed surgical lumbar disease even if surgery was not performed | Bilateral L4/ and L5/S1 zygapophyseal joints blockage percutaneously with 22G spinal needle by prilocaine (skin preparation) 10 mg bupivacaine and 5 mg methyl-prednisolone | Diclofenac sodium 100 mg/day, thiocolchicoside 8 mg/day for 5 days and recommended bed rest for 4 days |
5. | Kawu et al. [30] Nigeria | Intervention n = 10 60 % male, mean age 42.3 (±12.2) years Control n = 8 60 % male, mean age 46.7 (±10.4) years | Inclusion criteria: Chronic pain of more than 3 months’ duration, not responding to conventional drugs Non-radicular low back pain Focal tenderness over the facet joint elicited by digital pressure MRI features of FJA Exclusion criteria: Radicular pain radiating below the knee MRI findings of nerve root compression Clinical or imaging of infection and neoplastic disease | 0.5 ml of 0.25 % bupivacaine and 0.5 ml (20 mg) of methyl-prednisolone acetate were injected into the tender joints | Physiotherapy: patients had McKenzie regime |
6. | Ribeiro et al. [31] Brazil | Intervention n = 31 80.6 % female, mean age 63.4 years Control n = 29 82.8 % female, mean age 64.3 years | Inclusion criteria: Male and female patients aged between 18 and 80 years Continuous or intermittent low back pain for 3 months or longer Diagnosis of facet joint syndrome Pain upon baseline with an intensity of 4–8 on a 10-cm visual analogue scale (VAS) Informed consent Exclusion criteria: Known diagnosis of low back pain of an origin other than the facet joints Prior surgery on the spine Uncontrolled diabetes, systemic arterial hypertension, or glaucoma Diabetes with insulin use Fibromyalgia Changes in medications used for low back pain during the previous 2 months Allergy to the contrast medium Pregnancy or suspected pregnancy Current involvement in litigation |
n = 31 L3–L4, L4–L5, L5–S1 injected bilaterally with 1 ml (20 mg) triamcinolone hexacetonide for total of 120 mg and 1 ml lidocaine |
n = 29 Intramuscular injections of 1 ml (20 mg) of triamcinolone hexacetonide and 1 ml of lidocaine on 6 surface points of the lumbar paravertebral musculature |
Injection procedures and injectate
Sham/placebo controls
Conservative treatments
Excluded studies
Measures of outcome (i.e. pain and disability)
References | Outcome measures: pain | Outcome measures: disability | Measuring points | Outcomes: pain | Outcomes: disability |
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(a) Trials Injection verses sham control | |||||
Lilius 1989 [26] | Pain Visual Analogue Scale (VAS) 0–100 mm (no anchors given) | Objective disability was graded one to three for the patient standing, walking, sitting, sitting with legs extended, climbing onto the examination table and dressing. A disability score, ranging from 6 to 18 was constructed by adding the six variables | Baseline then 1 h, 2 and 6 weeks post-treatment and for pain (only) at 3 months | Mean probability for p value differences between groups (combined cortisone vs. saline) = 0.3375 (mean and SD) pain score on a scale of 0–100 mm for all 109 patients Before injection = 49.2 (22.3) 1 h = 30.9 (25.6) 2 weeks = 35.8 (25.9) 6 weeks = 40.7 (25.7) 3 months = 43.3 (26.6)
p < 0.0001 | Mean probability for p value differences between groups (combined cortisone vs saline) = 0.1206 (mean and SD) Disability score ranging from 6 to 18 constructed from 6 variables scoring from 1 to 3: (standing, walking, sitting, sitting with legs extended, climbing onto examination table and dressing) Before injection = 10.3 (1.7) 1 h = 8.9 (2.3) 2 weeks = 9.1 (2.1) 6 weeks = 9.1 (1.9)
p < 0.0001 |
Carette et al. [27] | Pain intensity: The McGill pain questionnaire (for this review we only include the mean present pain intensity variable) Also: A VAS, 0 = no pain to 10 = very severe pain | A modified Sickness Impact Profile. Eating and communication variables removed (by authors) as not related to LBP | Baseline then 1, 3 and 6 months post intervention | Mean present pain intensity, intervention, baseline = 2.7 Mean present pain intensity, control, baseline = 2.8 Mean present pain intensity, intervention, 1 month = 2.3, control = 2.6 Mean present pain intensity, intervention, 6 months = 2.1, control = 2.9 Baseline mean VAS, intervention, 6.3, control, 6.2 1 month mean VAS intervention, 4.5, control 4.7 Difference (95 % CI) = −0.2 (−1.1 to 0.8) 6 month mean VAS (0–10 cm scale) = 4.0 (methyl) = 5.0 (placebo) Difference (95 % CI) = −1.0 (−2.0 to −0.1) | Mean sickness impact profile, intervention, baseline, 11.4, control 13.4 Mean sickness impact profile intervention, 1 month 9.3 control 9.8 Difference (95 % CI) = −0.5 (−2.8 to 1.7) Mean sickness impact profile, intervention, 6 month, 7.8 control 10.8 Difference (95 % CI) = −3.0 (−6.2 to 0.2) |
Ribeiro et al. [31]*
| A 10 cm VAS, no anchors are given | Roland–Morris Disability Questionnaire | Baseline then 1, 4, 12 and 24 weeks after intervention | Intervention group mean (CI) VAS pain: T0 = 7.0 (6.5–7.4), T1 = 4.0 (3.0–5.0), T4 = 4.0 (3.0–5.-), T12 = 4.7 (3.5–5.7)
T24 = 5.3 (4.4–6.1), (p < 0.001) Control group mean (CI) VAS pain: T0 = 6.8, (6.2–7.3), T1 = 4.0 (3.0–4.9), T4 = 3.6 (2.3–4.7), T12 = 6.1 (5.0–7.0), T24 = 5.8 (4.5–6.9), (p < 0.001) No differences between the two groups | Intervention group mean (CI) Roland–Morris disability questionnaire: T0 = 15 (13.1–16.8), T1 = 11.5 (9.1–13.7), T4 = 10.2 (7.8–12.4), T12 = 10.6 (8.2–12.9), T24 = 10.9 (8.2–13.5), (p < 0.001) Control group mean (CI) Roland–Morris disability questionnaire: T0 = 16.4 (14.2–18.6), T1 = 13.4 (10.6–16.2), T4 = 12.2(9.7–14.6), T12 = 14.7 (12.3–16.9), T24 = 13.4 (10.8–15.9), (p < 0.001) No differences between two groups over time. However analysis at each time point showed statistical difference at week 12 (p = 0.01) |
(b) Injection verses conservative treatment control | |||||
Mayer et al. [28]*
| Pain intensity: A 10-cm line VAS, 0 = no pain to 10 = most severe pain | The Million VAS, represents the answers to 15 items on how pain affects activities of daily living, with a range from ‘no disability (0) to ‘most disability’ (150) | Baseline to follow-up 5–7 weeks | Intervention group pain intensity: Pre 6.3 (±1.5), post 5.4 (±1.6). p ≤ 0.003, a 53 % Control group Pre 6.7 (±1.8), post 5.9, (±2.1). p ≤ 0.004, a 50 % improvement Between groups differences not significant | Intervention group Million VAS: Pre 99.7 (±16.7), post 85.6 (±21.5). p ≤ 0.001, a 72 % improvement Control group Pre 100 (±29.2), post 92.2 (±25.1). p ≤ 0.003, a 68 % improvement Between groups differences not significant |
Celik et al. [29] | Noted as a VAS but no clear definition | Modified Oswestry low back pain disability questionnaire (ODQ) | Baseline then first and fifth days and first, third and sixth month | Intervention group: VAS pre-treatment = 8. Immediately after = 2. 1st month = 1. 3rd month = 5. 6th month = 2 Control group: VAS pre-treatment = 7. Immediately after = 3. 1st month = 2. 3rd month = 4. 6th month = 5 Decrease in VAS scores in post-treatment, 1st, 3rd and 6th month were not statistically significant (p > 0.005) Between-group differences not reported | Intervention group: ODQ pre-treatment = 23. Immediately after = 5. 1st month = 5. 3rd month = 11. 6 months = 3 Control group: ODQ pre-treatment = 21. Immediately after = 9. 1st month = 4. 3rd month = 7. 6th month = 11 Reduction in ODQ scores in intervention group was greater than in control group (p < 0.005) Between-group differences not reported |
Kawu et al. [30] | Noted as a VAS but no clear definition | Oswestry disability index | Baseline then 6 weeks, 3 and 6 months | Intervention group VAS pain: Male: pre-intervention = 7.8 ± 1.9, 6-week score = 5.9 ± 2.1, 3-month score = 4.5 ± 1.3 6-month score = 4.1 ± 1.7 Females: pre-intervention = 7.2 ± 1.6, 6-week score = 5.1 ± 2.1, 3-month score = 4.1 ± 1.5, 6-month score = 3.9 ± 1.2 Control group VAS: Male: Pre-intervention = 7.4 ± 2.1, 6-week score = 6.8 ± 1.9, 3-month score = 5.8 ± 1.6, 6-month score = 5.2 ± 1.3 Female: Pre-intervention = 7.0 ± 2.3, 6-week score = 6.4 ± 1.5, 3-month score = 5.2 ± 1.4, 6-month score = 4.8 ± 1.9 Post intervention mean VAS significantly lower in intervention group (p = 0.032) | Intervention group ODI: Male: Pre-intervention = 58.6 ± 6.8, 6-week score = 49.7 ± 6.2, 3-month score = 42.3 ± 5.5, 6-month score = 39.6 ± 4.9 Females: Pre-intervention = 52.3 ± 9.2, 6-week score = 47.0 ± 7.1, 3-month score = 38.9 ± 6.8 6-month score = 37.1 ± 5.2 Control group ODI: Male: Pre-intervention = 59.0 ± 8.6, 6-week score = 55.3 ± 5.4, 3-month score = 53.7 ± 7.2, 6-month score = 51.8 ± 6.3 Female: Pre-intervention = 56.3 ± 8.9, 6-week score = 53.4 ± 7.1, 3-month score = 38.7 ± 6.3, 6-month score = 37.1 ± 4.9 FJI group fared consistently better with a low mean score against the mean score against the mean score of the physiotherapy group. No direct information specifically reported for the ODI except graph showing ODI against time |
Length of follow-up
Quality assessment profiles
Allocation (selection bias)
Blinding (performance bias and detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Effects of interventions
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Injection versus sham control.
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Injection versus conservative treatment control.