Browsing articles in "Dolor"

Eficacia de los ultrasonidos y ondas de choque en la lumbalgia

Imagen ondas de choque espaldaPor suerte, cada vez son más los artículos sobre distintas técnicas terapéuticas usadas en Rehabilitación y Fisioterapia.
En éste caso se realiza una revisión sobre la eficacia, seguridad, efectividad y coste-efectividad del uso de ultrasonidos y ondas de choque en la lumbalgia. A pesar de los resultados y de lo tajante de las conclusiones, creo que el impacto del mismo en la práctica clínica tampoco va a ser excesivo, ya que la disponibilidad de las ondas de choque aún está bastante limitada y  sobre todo el uso de ultrasonidos en la lumbalgia no es una indicación generalizada.
Creo que se están dando pasos para alcanzar una Rehabilitación más científica, más basada en la evidencia y más alejada de “la tradición”, pero aún queda recorrido, no sólo parar alcanzar éstos conocimientos sino también para saber comunicarlos (¿cuántas derivaciones de otros especialistas solicitando terapias no indicadas, sin ninguna evidencia, se ven al final del día? ¿cuántos pacientes vienen simplemente a recibir su sesión anual de “corrientes”?, ¿cuántas terapias sin evidencia se siguen aplicando en las salas? etc., etc.)

Spine J. 2011 Oct;11(10):966-77. Epub 2011 Apr 9.
The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review.
Seco J, Kovacs FM, Urrutia G.


  • Tipo: Revisión sistemática.
  • Conclusiones: La evidencia disponible no apoya la eficacia de los ultrasonidos o la onda de choque para el tratamiento del dolor lumbar. ECA de alta calidad son necesarios para evaluar su eficacia en comparación con placebo, y su eficacia y costo-efectividad en comparación con otros procedimientos que han demostrado su eficacia en el dolor lumbar. En ausencia de tales pruebas, el uso clínico de estas formas de tratamiento no se justifica y debe ser evitado.

Podemos leer el abstract: Eficacia de los ultrasonidos y ondas de choque en la lumbalgia.


Ácido valproico y valproato de sodio en dolor neuropático y fibromialgia. Revisión Cochrane

Ácido Valproico

Cochrane Database Syst Rev. 2011 Oct 5;(10):CD009183.
Valproic acid and sodium valproate for neuropathic pain and fibromyalgia in adults.
Gill D, Derry S, Wiffen PJ, Moore RA.

BACKGROUND: Valproic acid and its sodium salt (sodium valproate) are antiepileptic drugs that are sometimes used to treat chronic neuropathic pain and fibromyalgia, although they are not licensed for this use.

OBJECTIVES: To evaluate the analgesic efficacy and adverse effects of valproic acid and sodium valproate in the management of chronic neuropathic pain and fibromyalgia.

SEARCH STRATEGY: We identified randomised controlled trials (RCTs) of valproic acid and sodium valproate in acute, and chronic pain by searching MEDLINE, EMBASE and Cochrane CENTRAL to June 2011, together with reference lists of retrieved papers and reviews.

SELECTION CRITERIA: RCTs that were double blind and of eight-weeks duration or longer, reporting on analgesic effects and adverse events with valproic acid and sodium valproate in the treatment of chronic neuropathic pain and fibromyalgia.

DATA COLLECTION AND ANALYSIS: Two review authors independently extracted results and scored for quality. We extracted efficacy and adverse event data, and examined issues of study quality.
MAIN RESULTS: We included three studies, two in diabetic neuropathy (42 participants treated with valproate, 42 with placebo), and one in post-herpetic neuralgia (23 treated with divalproex sodium, 22 with placebo). Study duration was eight or 12 weeks. No studies were found in fibromyalgia.Only one study reported one of our primary outcomes (>/= 50% pain relief), while all three reported group means for pain reduction from baseline to endpoint. In all three studies; efficacy results were given only for participants who completed the study. One study in diabetic neuropathy and the study in post-herpetic neuralgia reported significant differences between active and placebo groups, but there were insufficient data for reliable pooled analysis.More adverse events were reported with active treatment than placebo, and included nausea, drowsiness and abnormal liver function tests. One participant taking sodium valproate withdrew due to serious derangement of liver enzymes.

AUTHORS’ CONCLUSIONS: These three studies no more than hint that sodium valproate may reduce pain in diabetic neuropathy, and divalproex sodium in post-herpetic neuralgia, but the use of `completer` analysis may overestimate efficacy, and there were too few data for pooled analysis of efficacy or harm, or to have confidence in the results of the individual studies. There is insufficient evidence to support the use of valproic acid or sodium valproate as a first-line treatment for neuropathic pain. There is more robust evidence of greater efficacy for a small number of other drugs.

Texto completo: Ácido valproico y valproato de sodio en dolor neuropático y fibromialgia. Revisión Cochrane


Efecto de la inyección epidural de esteroides o de solución salina en la radiculopatía lumbar crónica

BMJ. 2011 Sep 13;343:d5278. doi: 10.1136/bmj.d5278.
Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. 
Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A, Nygaard O, Hasvold T, Ingebrigtsen T.

OBJECTIVE: To assess the efficacy of caudal epidural steroid or saline injection in chronic lumbar radiculopathy in the short (6 weeks), intermediate (12 weeks), and long term (52 weeks).
DESIGN: Multicentre, blinded, randomised controlled trial.
SETTING: Outpatient multidisciplinary back clinics of five Norwegian hospitals.
PARTICIPANTS: Between October 2005 and February 2009, 461 patients assessed for inclusion (presenting with lumbar radiculopathy >12 weeks). 328 patients excluded for cauda equina syndrome, severe paresis, severe pain, previous spinal injection or surgery, deformity, pregnancy, ongoing breast feeding, warfarin therapy, ongoing treatment with non-steroidal anti-inflammatory drugs, body mass index >30, poorly controlled psychiatric conditions with possible secondary gain, and severe comorbidity.
 INTERVENTIONS: Subcutaneous sham injections of 2 mL 0.9% saline, caudal epidural injections of 30 mL 0.9% saline, and caudal epidural injections of 40 mg triamcinolone acetonide in 29 mL 0.9% saline. Participants received two injections with a two week interval.
MAIN OUTCOME MEASURES: Primary: Oswestry disability index scores. Secondary: European quality of life measure, visual analogue scale scores for low back pain and for leg pain.
 RESULTS: Power calculations required the inclusion of 41 patients per group. We did not allocate 17 of 133 eligible patients because their symptoms improved before randomisation. All groups improved after the interventions, but we found no statistical or clinical differences between the groups over time. For the sham group (n=40), estimated change in the Oswestry disability index from the adjusted baseline value was -4.7 (95% confidence intervals -0.6 to -8.8) at 6 weeks, -11.4 (-6.3 to -14.5) at 12 weeks, and -14.3 (-10.0 to -18.7) at 52 weeks. For the epidural saline intervention group (n=39) compared with the sham group, differences in primary outcome were -0.5 (-6.3 to 5.4) at 6 weeks, 1.4 (-4.5 to 7.2) at 12 weeks, and -1.9 (-8.0 to 4.3) at 52 weeks; for the epidural steroid group (n=37), corresponding differences were -2.9 (-8.7 to 3.0), 4.0 (-1.9 to 9.9), and 1.9 (-4.2 to 8.0). Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend.
CONCLUSIONS: Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy. Trial registration Current Controlled Trials ISRCTN No 12574253.


Eficacia a medio plazo de las ondas de choque extracorpóreas en la tendinitis calcificante de hombro

J Shoulder Elbow Surg. 2011 Jul;20(5):845-54. Epub 2011 Jan 13.
The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. 
Lee SY, Cheng B, Grimmer-Somers K.

BACKGROUND: This systematic review explored the midterm effectiveness of extracorporeal shockwave therapy (ESWT) in reducing pain and improving shoulder function. Calcified rotator cuff tendinitis is a common cause of chronic shoulder pain that leads to significant pain and functional limitations. ESWT is an alternative to surgery when conservative treatments such as nonsteroidal antiinflammatory drugs, steroidal injections, and physiotherapy fail to relieve symptoms. It is hypothesised that ESWT is effective in the midterm for reducing pain and improving function for patients with chronic calcific tendinitis and that a dose-response relationship exists in the treatment parameters for effectiveness.
MATERIALS AND METHODS: Articles were electronically searched from the Cochrane Controlled Trials Register, MEDLINE, CINAHL, PUBMED, EMBASE, SPORTSDiscus and PEDro using a comprehensive search strategy. Studies were included if they were randomized controlled trials testing the midterm effectiveness of ESWT for chronic calcific tendonitis. Methodologic quality was assessed by PEDro (total score = 10). The strength of the evidence was reported using the National Health and Medical Research Council body of evidence framework.
RESULTS: Six of the nine included studies scored 7 or more for methodologic quality. All studies had follow-up periods of at least 6 months. Common methodologic flaws were insufficient blinding of clinicians and assessors. There was consistent evidence of midterm effectiveness of ESWT in reducing pain and improving shoulder function for patients with chronic calcified tendinitis.
DISCUSSION: ESWT is a potential alternative to surgery with good mid-term effectiveness and minimal side effects. This review noted several limitations with the current body of evidence. Studies were mainly from a few European countries involving medical doctors, with a lack of diverse perspectives and effectiveness evaluation from other health professionals who might use this treatment option for patients with chronic calcific tendinitis. Further, the different outcome measures used and inadequate reporting details in the included studies did not permit a quantitative synthesis of the effectiveness of this treatment. A lack of follow up period beyond one year in the studies also precluded conclusion to be made on the longer term effectiveness of ESWT.
CONCLUSION: Due to variable treatment parameters (eg dosage), this review was unable to provide clear guidance of the dose-effect of the midterm effectiveness of ESWT. Studies of better methodologic design using standardized treatment protocols and studies with longer follow-up are required.