Original Contribution
Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study

https://doi.org/10.1016/j.ajem.2019.01.015Get rights and content

Abstract

Introduction

Low back pain (LBP) is a common complaint originating from muscles

Myofascial pain syndrome (MPS) is mainly associated with trigger points (TrP) in the muscle tissue. We compared the intravenously administered non-steroidal anti-inflammatory drug (NSAID) and trigger point injection (TPI) in the treatment of LBP patients admitted to the emergency department due to pain caused by TrPs.

Material and method

After randomization, NSAID was administered intravenously in group 1 and TPIs were performed as specified by Travell and Simons in group 2. The TrPs were identified with the anamnesis and physical examination

Demographic characteristics and vital signs of the patients were recorded. Pain scores were measured with the Visual Analogue Scale (VAS) at admission; and in minutes 5, 10, 15, 30, and 60.

Results

There were 32 patients in group 1 and 22 patients in group 2. The demographics, vital signs, and pain scores at admission were not statistically significantly different between the groups. The pain scores decreased significantly in the TPI group. During the 60 min' follow-up period, the mean VAS pain score decreased by 0.41 ± 1.30 in the TPI group and by 2.59 ± 2.37 in the NSAID group (p < 0.001). Respond the treatment was significantly higher group TPI than Group NSAID (21/22 vs 20/32 respectively, p = 0.008).

Conclusion

In this small randomized study with several methodological limitations, TPI was superior to the intravenous NSAIDs in the treatment of acute LBP due to TrPs. TPI can be used in the emergency departments for the acute treatment of LBP in selected patients.

Introduction

Acute or chronic pain results in a remarkable burden for mankind from the clinical, economic, and social aspects. The most common cause of physician visits is the pain. Pain caused extra burden in the patients and their families; including opioid use and dependence, depression, poor social relationships and economic costs [1]. The feeling of pain is, in fact, one of the control mechanisms of the body. Pain transmits the information about the presence of injuries in the body tissues to the brain, allowing for awareness. This is a protective mechanism essentially [2].

Low back pain (LBP) is a common and expensive medical condition. LBP rarely refers to a serious disorder. The annual prevalence of low back pain in the US is estimated between 15% and 20% and its lifetime prevalence is over 60% [3]. LBP is one of the most common causes of admission to emergency departments (ED) [4,5]. LBP related accounts for approximately 2.5% of ED visits [6,7]. However the prevalence and analgesic management of LPB in the ED is still unclear [8].

Myofascial pain syndrome (MPS) is an uncommon cause of musculoskeletal pain. MPS is a neuromuscular disorder characterized by localized muscle tenderness and often manifests with pain in the back, shoulders, lower back; and tension-type headaches. The origin of the MPS is the presence of a hyperalgesic spot in the form of a painful band and it is called as a trigger point. A trigger point (TrP) is defined as a sensitivity felt at deeper levels in the musculoskeletal tissue, causing pain in the zone of reference, which is the region of pain associated with the TrP. The TrPs are localized only in the muscles and myofascial trigger points (MTrPs) are a common source of (regional) pain in patients presenting with musculoskeletal pain, with a lifetime prevalence of up to 85% in the general population [9]. The pain is usually localized in the TrP, and referred to the surroundings. The main objective in the treatment of MPS is to break the pain cycle by eliminating the trigger points. Currently, several therapies are available for treating myofascial trigger points; including massaging, stretching, dry needle injections, electrical stimulation, cold laser treatment, and ultrasound [10]. An insufficient treatment of pain will cause a significant socioeconomic burden, as well as, a reduction in the quality of lives of the affected individuals.

In our study, we aimed to compare the intravenously administered nonsteroidal anti-inflammatory drug (NSAID) treatment versus trigger point injection (TPI) in patients admitted to the emergency department due to pain caused by an LBP with TrPs.

Section snippets

Study design and setting

All patients were informed about the study and its procedures, and informed consents on paper were collected from the agreeing volunteers before their inclusion in the study. The study was approved by the Ethics Committee at Ataturk University Faculty of Medicine. Our study was conducted in the emergency department at Ataturk University, Faculty of Medicine between 01.04.2018 and 30.10.2018. The patients presenting to the emergency department with the complaint of LBP, who had trigger points as

Results

Our study was conducted on patients who presented to the emergency department due to LBP associated with identified TrPs. The patients were allocated to two groups at the time of admission so that a total of 80 individuals would be included in the study with 40 patients in either group. As some patients did not agree to participate in the study or some met with at least one of the exclusion criteria, a total of 54 patients completed the study with 22 (40.7%) patients in the TPI group and 32

Discussion

Our study was conducted on LBP patients who presented to the emergency department. Patients presenting to the emergency department due to LBP with TrPs; identified in the deep lumbar paraspinal muscles, right and left quadratus lumborum, and right and left gluteus medius muscles by means of the medical history and physical examination were included in the study. The aim of our study was to investigate the efficacy of trigger point injection in the emergency department. For this purpose,

Conclusion

In this small randomized study with several methodological limitations, TPI was superior to the intravenously administered NSAID in the acute treatment of LBP caused by trigger points. We believe that the trigger point injection should be a part of the acute treatment of LBP in the selected patient group.

References (33)

  • S. Khalid et al.

    Neuroanatomy and neuropsychology of pain

    Cureus

    (2017)
  • S.J. Atlas et al.

    Evaluating and managing acute low back pain in the primary care setting

    J Gen Intern Med

    (2001)
  • C. Liu et al.

    Effectiveness of interventions to decrease image ordering for low back pain presentations in the emergency department: a systematic review

    Acad Emerg Med

    (2018)
  • R.A. Deyo et al.

    Low back pain in primary care

    BMJ

    (2014)
  • J. Edwards et al.

    Prevalence of low back pain in emergency settings: a systematic review and meta-analysis

    BMC Musculoskelet Disord

    (2017)
  • M.S. Jafri

    Mechanisms of myofascial pain

    Int Sch Res Notices

    (2014)
  • Cited by (24)

    • Trigger Point Injections

      2022, Physical Medicine and Rehabilitation Clinics of North America
      Citation Excerpt :

      In a study where patients presented to the emergency department with lumbar myofascial pain, patients were randomized to either intravenous (IV) nonsteroidal anti-inflammatory drugs (NSAIDs; 50 mg dexketoprofen) or TPI with 1.0% lidocaine. Of 54 patients enrolled in this RCT, TPIs were found to have superior analgesic effect compared with IV NSAIDs at all studied time points up to 60 minutes after intervention.71 Though superior to pharmacologic, the type of injectate did not seem to make a substantial difference in most studies.

    • The therapeutic management of back pain with and without sciatica in the emergency department: a systematic review

      2020, Physiotherapy (United Kingdom)
      Citation Excerpt :

      In two studies [18,23] only the patient was blinded to treatment. In two studies [29,30] multiple superficial injections were compared to a single infusion and no blinding occurred. Of the acupuncture studies one [31] attempted to blind the participants by providing sham acupuncture, one [32] blinded the outcome assessors and acupuncturists to pharmacological therapy and one [14] made no attempt at blinding.

    • Comparison of topical capsaicin and topical piroxicam in the treatment of acute trauma-induced pain: A randomized double-blind trial

      2020, American Journal of Emergency Medicine
      Citation Excerpt :

      The mean decrease in the VAS (delta VAS) and the mean of the percentage of reduction in the VAS scores were calculated. The study outcomes were stated as a >50% decrease in the VAS scores at the end of treatment [10] and a final score of ≤4 [11]. These two criteria were used to define clinically effective treatment.

    • Comparison of intradermal mesotherapy with systemic therapy in the treatment of low back pain: A prospective randomized study

      2020, American Journal of Emergency Medicine
      Citation Excerpt :

      The correct use of mesotherapy requires clinical and pharmacological skills, aseptic technique, and convenient hygiene and sterilization procedures [8]. Our center has had a clinical experience in which the intradermal administration of drugs via mesotherapy and the trigger point injections in patients with musculoskeletal pain [4,17]. We also composed a cocktail solution, including a mixture of thiocolchicoside, lidocaine and tenoxicam, can be injected intradermally without complication and our clinical experience suggests our cocktail solution can be used effectively via mesotherapy [17].

    View all citing articles on Scopus
    View full text