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Levels of Evidence for Epidural Steroid Injections To the Editor: In the review of conservative treatments for mechanical neck disorders (MND) by Gross, et al1, there seems to be an inconsistency in the use of levels of evidence for epidural steroid injections. According to the authors' Table 2, evidence from single low-quality trials should be graded as "limited." And low-quality trials were determined by scores of less than 3 on Jadad's scale and less than 6 on van Tulder's scale. For epidural steroid injections, the only trial that they found (Stav, et al2, their reference 48) had a trial method score of 2 on Jadad's scale and 3 on van Tulder's scale. In spite of this, the evidence for epidural steroid injections is graded as "Moderate" both in Table 4 and in the Results section. Consequently, we think that the level of evidence should be changed to "Limited" for epidural steroid injections. In addition, we are concerned that the Conclusion in the abstract states that intramuscular lidocaine injections are effective for chronic MND, when the conclusion is based upon a single trial3 with a poor trial method score of 1 on the Jadad scale and 2 on the van Tulder scale. In our opinion, the possible beneficial effects of these 2 injection therapies remain uncertain, and the review seems to have overrated their value. JAN M. BJORDAL, PT, PhD; JON JOENSEN, PT, MSc, Bergen University College, Institute for Physiotherapy, and University of Bergen, Mollendalsvn. 6, Bergen 5009, Norway. Address reprint requests to Dr. Bjordal. E-mail: jmb@hib.no 2. Stav A, Ovadia L, Sternberg A, Kaadan M, Weksler N. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand 1993;37:562-6. [MEDLINE] 3. Esenyel M, Caglar N, Aldemir T. Treatment of myofascial pain. Am J Phys Med Rehabil 2000;79:48-52. [MEDLINE]
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