Chronic Spinal Pain Clinical Trial
Official title:
Repetitive Transcranial Magnetic Stimulation Combined With Steroid Joint Injection for the Treatment of Chronic Spinal Pain: Protocol for a Pilot Randomized Controlled Trial
Chronic spinal pain (CSP) is one of the most common chronic pain conditions globally. Steroid joint injections (SJI) are a routine treatment option for patients with CLBP that is recalcitrant to other treatments. However, SJI has been shown to have limited long-term efficacy with patients often requiring another injection within months to adequately control pain. One option to prolong the analgesic effects of SJI is to use a type of noninvasive brain stimulation called repetitive transcranial magnetic stimulation (rTMS). Previous studies have shown rTMS may be capable of providing long-term pain relief in patients with chronic back pain. However, the literature on rTMS in patients with CSP is limited and no study has explored rTMS in patients receiving recurrent SJI for pain control. What is also unclear is the mechanisms through which rTMS might exert therapeutic effects on CSP. Systemic inflammation has been shown to have a key role in the initiation and maintenance of chronic pain, particularly through the actions of serum pro- and anti-inflammatory proteins. In this pilot randomized controlled trial study, we'll be investigating if combining rTMS with SJI in CSP individuals will enhance or prolong the analgesic effects of SJI alone. We'll also be studying the relationship between specific pro- and anti-inflammatory proteins and rTMS/SJI treatment response. The investigators hypothesize that a combined rTMS and SJI intervention will be feasible, tolerable, and safe and will have larger and longer-lasting effects on CSP than a sham rTMS and SJI intervention. Further, it is hypothesized that anti-inflammatory proteins, such as IL-4 and IL-9, will be upregulated, and pro-inflammatory proteins, such as IL-6, downregulated, relative to baseline, in response to the active rTMS and SJI intervention but not in response to the sham rTMS and SJI intervention.
Status | Recruiting |
Enrollment | 40 |
Est. completion date | December 31, 2024 |
Est. primary completion date | July 31, 2024 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years and older |
Eligibility | Inclusion Criteria: - Currently receiving recurrent steroid joint injections for control of chronic spinal pain at the St. Joseph's Health Centre Pain Clinic in London, Ontario, Canada, - Have pain in the spinal region of an intensity =4 out of 10 in the week before your most recent steroid joint injection, - Have received at least 2 steroid joint injections within the last 12 months at regular intervals - Have had a consistent medication regimen for the past 3 months. Exclusion Criteria: - Unable to read, understand, and speak English and are not able to give consent - Known or suspected serious spinal pathology (tumour, fracture, dislocation, scoliosis) - Spinal surgery in the past 12 months - History of uncontrolled mental health condition(s) - Have an inflammatory or autoimmune disease - Meet any specific rTMS-related exclusion criteria listed on the safety screening questionnaire (S1; Rossi et al., 2008). |
Country | Name | City | State |
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Canada | Parkwood Institute (Main Building) | London | Ontario |
Lead Sponsor | Collaborator |
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Lawson Health Research Institute | St. Joseph's Health Care London, Western University, Canada |
Canada,
Type | Measure | Description | Time frame | Safety issue |
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Primary | Measures of feasibility and tolerability | Data for feasibility, tolerability, and safety will be analyzed using descriptive statistics. Feasibility and tolerability will be measured as (1) the time taken to complete the recruitment of 40 participants, (2) the number of sessions attended by each participant, (3) the number of dropouts in each group, (4) the proportion of participants recruited from the total number screened, and (5) the willingness of each participant to undergo therapy on an 11-point numerical rating scale with 'not at all willing' at 0 and 'very willing' at 10 (measured at baseline). | Through study completion, an average of 24 weeks | |
Primary | Measures for safety | Safety will be presented as any adverse reaction reported on verbal questioning at each session. The assessor will record a description of any adverse reactions along with the severity, duration and how the adverse reaction was managed. The number of participants reporting adverse reactions, and the duration and severity of the adverse reactions will be reported. | Through study completion, an average of 24 weeks | |
Secondary | Pain Numeric Rating Scale | Pain severity will be assessed at baseline and weekly until week 24 using the 11-point Pain Numeric Rating Scale. | Weeks 1 through 24 | |
Secondary | Brief Pain Inventory - Short Form (BPI-SF) | Pain severity and the impact of pain on the patient's daily functioning will be assessed using the 9-item, Brief Pain Inventory short form at baseline, weeks 4, 8, 12, and 24. | Weeks 4, 8, 12, 24 | |
Secondary | 12-Item Short Form (SF-12) | The 12-item short form (SF-12) will be used to assess the quality of life and will be taken at baseline, weeks 4, 12 and 24. | Weeks 4, 8, 12, 24 | |
Secondary | Oswestry Disability Index (ODI) | Disability will be assessed using the Oswestry Disability Index (ODI) at baseline, weeks 4, 8, 12, and 24. The 12-item short form (SF-12) will be used to assess the quality of life and will be taken at baseline, weeks 4, 12 and 24. Finally, as rTMS has previously been shown to positively affect depression and anxiety symptoms, the Depression Anxiety and Stress Scale 21 (DASS-21) will be used to monitor any potential effects our rTMS treatment has on mood. This will be administered at weeks 4, 12, and 24. | Weeks 4, 8, 12, 24 | |
Secondary | Global Rating of Change Scale (GRC) | A 15-point GRC, with -7 "a very great deal worse", 0 "about the same", to 7 "a very great deal better", will be administered to assess participants' perception of symptom improvement or worsening in response to treatment. The GRC will be administered in weeks 4, 12 and 24. | Weeks 4 - 24 | |
Secondary | Depression Anxiety and Stress Scale 21 (DASS-21) | As rTMS has previously been shown to positively affect depression and anxiety symptoms, the Depression Anxiety and Stress Scale 21 (DASS-21) will be used to monitor any potential effects our rTMS treatment has on mood. This will be administered at weeks 4, 12, and 24. | Weeks 4, 12, 24 | |
Secondary | Measures of Inflammatory Markers | Blood will be drawn at baseline, week 6, and week 12 to explore the association between inflammatory markers and treatment response. Serum concentration of interleukins IL-4 and IL-6 will be quantified using a 32x3 simple plex multianalyte cartridge for the Ella automated immunoassay system (ProteinSimple, San Jose, California). Quantification of serum IL-9 will be performed in triplicate via enzyme-linked immunosorbent assay (ThermoFisher Scientific, Massachusetts, USA). Samples will be prepared and loaded into the cartridge for measurement according to standard instructions provided by the manufacturers. | Weeks 1, 6, 12 |
Status | Clinical Trial | Phase | |
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Completed |
NCT02098005 -
Pain Neuroscience Education Combined With Cognition-targeted Motor Control Training
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N/A |