New technology to treat chronic lower back pain


Are you suffering from chronic lower back pain (CLBP)  that just won’t go away? Are you tired of having to continually struggle with your physiotherapists to try and “get by on a daily basis”? Do you feel you are on on a “hiding to nothing” when it comes to your back pain?

Well maybe there is a new technology option for you. Dr. Dominic Hegarty (Clinical Director Pain Relief Ireland) may have an option. In this weeks edition of The Medical Independent (March 2019) he highlights the availability of Reactiv8 as a neuromodulation device to help control the symptoms. “This approach uses technology to help strengthen the multifidis muscle group in the lumbar region and targets this on a daily basis. While it is not for everyone it does give us a realistic option to help individuals troubled by back pain where surgery or other pain intervention are not suitable or contraindicated. The studies support this as a long-term solution with significant improvements in daily functional capacity.

Why does CLBP persist in some individuals?

The pathophysiology of CLBP remains complex and multifaceted. Multiple anatomic structures and elements of the lumber spine (e.g. bones, ligaments, tendons, disks, muscle) are all suspected to have a role and are generally referred to a “mechanical” lower back pain. The lumber spine also has an extensive sensory innervation network that can generate nociceptive signals representing responses to tissue-damaging stimuli. While most chronic pain cases likely involve mixed nociceptive and neuropathic aetiologies the clinical description of CLBP tends to suggest that the nociceptive system is the primary pathway. The fact that most CLBP does not respond to traditional agents used to manage neuropathic pain (pregabalin / gabapentin etc) would support this theory.

Nevertheless, as with any medical condition, it is prudent to ensure that every effort is made to exclude important and treatable causes that might mimic the presenting symptoms. For example one must consider the possibility of discogenic LBP, lumbar facet syndrome, myofascial pain, sacroiliac joint syndrome and malignancy. Each of these diagnosis require specific investigations and each have their own treatment pathway which is outside the scope of this article.

Is there a specific physical therapy program that should be used?

“Physiotherapy is a very important part of managing CLBP” says Dr. Hegarty and “Ideally the individual has a program that they use on a regular basis”. The style of each program can vary but a prospective study by Ben-Ami et al. (2017) of 189 patients with chronic LBP found that those who underwent a physical therapy program focused on dealing with obstacles to physical activity (an enhanced transtheoretical model intervention - ETMI), including low self-efficacy and fear avoidance, in order to increase recreational physical activity, experienced better reduction in long-term disability than did patients who underwent usual physical therapy. The investigators determined that at 12-month follow-up, patients who underwent the ETMI had significantly better results with regard to worst pain, physical activity, and physical health. (Ben-Ami et al. 2017)

Dr. D. Hegarty believes that this “supports the concept that exercise and insight are a valuable combination and should be encouraged”

So how can technology at Pain Relief Ireland help CLBP?

Recent developments in technology has resulted in regular stimulation of the multifidus muscle through a specific nerve in the lumbar region. This has shown to improve both pain levels and quality of life. The device known as “Reactiv8” has been developed by an Irish company (Mainstay) and is CE marked for global distribution. It has completed clinical trials in the USA, Europe and Australia. It has recently been approved for implantation in Ireland by the main health insurers. Dr. Hegarty is one such implanter and believes that this device can really make a significant impact for certain patients. “Correct patient selection is the cornerstone of any therapy and neuromodulation is no different” says Dr. Hegarty, “and Pain Relief Ireland, in conjunction with the Mater Private Hospital Cork, are delighted to be able to offer this option to suitable individuals”.

The ideal individual is outlined in table 1
Table 1 Key Indications for Reactiv8 Implantation
   a) Disabling chronic lower back pain only
  • Pain > 3 months in duration
  • Pain score >6 /10
  • Nociceptive Pain not neuropathic in nature
   b) Treatment tried to date includes
  • Physical Therapy
  • Oral Medication
  • Possible pain interventions such as facet / epidural injections
   c) Other options
  • Surgery not indicated
  • Psychologically willing to engage with therapy in the long-term
ACTION: If you met these criteria Contact Pain Relief Ireland for further assessment

 

Conclusion & Prognosis

In general the earlier CLBP is controlled the more greater the recovery potential. Activity is encouraged and should be assisted by suitable analgesics as soon as possible. At 1 month, 35% of patients can be expected to recover; at 3 months, 85% have recovered; and at 6 months, 95% have recovered. Unfortunately the recurrence of CLBP at 1 year is 62%. At 2 years, 80% of patients have had 1 or more recurrences.

Physical rehabilitation is a key element in the treatment pathway. Analgesics should be aimed at offering pain control to continue with the physical therapy. A graded structured program, focused on exercise and insight, is important if the individual is to recover as much as possible.

For refractory cases the availability of new restorative neurostimulation technology is for CLBP can offer a real solution and improve the long-term outcome. A simple pain consultant assessment can change an individual quality of life for good.

If you feel you, or a patient of yours, meet the criteria in table 1 these then perhaps Pain Relief Ireland can help.

Please Contact us requesting an assessment and we shall assess what the correct option are. The sooner you make that call the sooner you get back in control.

Abstracts taken from “The Medical Independent” March 2019

More information on Reactiv8 can be found at http://www.mainstay-medical.com/en/home

Figure 1 Shows radiological position of the electronic Reactiv8 leads in the lumbar region at the L2/3 level. The implanted power generator is noted.

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