Efficacy of Intradiscal Injection of Autologous BM-MSC in Worker Patients Affected by Chronic LBP Due to Multilevel IDD (ACTIVE)

Autologous Mesenchymal Stem/Stromal Cells for the Treatment of Workers Affected by Chronic Low Back Pain Due to Multilevel InterVErtebral Disc Degeneration: a Phase IIB Randomized Clinical Trial

ACTIVE is a phase II B efficacy monocenter, prospective, randomized, controlled double blinded trial, in which intra-discal autologous adult BM-MSC therapy will be compared with sham treated controls.

This trial will evaluate the efficacy of intradiscal injection of autologous BM-MSCs in workers affected by chronic low back pain (LBP) unresponsive to conventional therapy.

The efficacy will be evaluated 12 months after the treatment in terms of pain relief (VAS, Visual Analog Scale), functionality (ODI, Oswestry Disability Index), quality of life (SF36, Short Form - 36) and work ability index (WAI).

Study Overview

• Status: Completed
• Conditions: Chronic Low-back Pain; Intervertebral Disc Degeneration
• Intervention / Treatment: Drug: Autologous BM-MSC; Other: Sham Procedure

Detailed Description

Low back pain (LBP) is the main cause of disability in the world, affecting all occupational sectors with different incidence rates. It is estimated that 60 percent of all workers suffer from LBP during their careers, 10 percent of which become chronic (The Lancet. September 2017). Intervertebral disc degeneration (IDD) is widely recognized as a major contributor to LBP, responsible for at least 40 percent of cases. A key characteristic of IDD is loss of matrix integrity and biomechanical functional failure. Today, no therapy can restore intervertebral disc (IVD) function or provide long-term relief from symptomatic IDD. Current therapies are aimed at pain reduction. When these treatments fail, several types of surgery are performed but they are often related to side effects, disturbance of motion and other biomechanical consequences. New strategies concentrate on treating IDD at an early stage. Encouraging results from phase 1 and 2 clinical trials suggest that cell-based regenerative therapies may provide the world first effective therapy for LBP. LBP patients treated with bone marrow mesenchymal stromal/stem cells (BM-MSC) showed rapid and progressive improvement of functional indexes of 65 percent to 78 percent over 1 year after intradiscal administration without side effect. ACTIVE is an ambitious randomized clinical trial aimed at developing a treatment for IDD based on intradiscal injection of autologous BM-MSC to improve the quality of life of workers and the disability of patients with LBP. ACTIVE main aim is to generate efficacy and safety profiles of single injections of 15 million cells/mL of autologous BM-MSC for each disc affected by IDD (up to 4 discs) versus sham procedure. The regenerative potential of BM-MSC treatment will be assessed by Magnetic Resonance Imaging (MRI) technologies on quarterly basis up to 12 months.

• Study Type: Interventional
• Enrollment (Actual): 48
• Phase: Phase 2

Contacts and Locations

Study Locations

• Italy
  • Roma, Italy, 00128
    • Campus Bio-Medico University of Rome

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Workers (it means subject has worked at least 2 months, even if not continuously, in the last 6 months)
• Age between 18 and 65 years.
• Signed informed consent.
• Symptomatic chronic LBP due to moderate/severe IDD [modified Pfirrmann score 3-5 (Pfirrmann et al., 2001), Griffith score 4-8 (Griffith et al., 2007)] at max. 4 levels of the lumbar spine unresponsive to conservative treatment, physical and medical for at least 6 months. Physical treatment includes physiotherapy. Medical treatments includes AINS, paracetamol, opioids and myorelaxant.
• Annulus fibrosus intact, demonstrated by MRI.
• Pain baseline > 40 mm on VAS (0- 100).
• NSAID washout of at least 2 days before screening.
• Painkillers washout of at least 24 hours before screening.
• For females of childbearing potential, a negative pregnancy test must be documented at Screening.
• Men and women should use effective contraception during treatment and for at least 12 months after BM-MSC discontinuation. The complete list of contraceptive methods is described in the patient information sheet and in the paragraph 6.5. As a precautionary measure, breast-feeding should be discontinued during treatment with BM-MSC and should not be restarted after discontinuation of BM-MSC.

Exclusion Criteria:

• Non-workers (it means that the person has worked less than 2 months, although not continuously, in the last 6 months)
• Congenital or acquired diseases leading to spine deformations that may upset cell application (scoliosis, isthmus lesion, sacralization and hemisacralization, degenerative spondilolisthesis).
• Spinal segmental instability assessed by dynamic X-Ray.
• Symptomatic facet joints syndrome on MRI (facet joints hyperintensity and hypertrophy evaluated at coronal T2 weighted MRI).

• Prior to the screening visit, has received:

  • Oral corticosteroid therapy within the previous 3 months, OR
  • Intramuscular, intravenous or epidural corticosteroid therapy within the previous 3 months
• Presence of a 5th level with symptomatic IDD (modified Pfirrmann score 3-5, Griffith score 4-8) in the lumbar spine.
• Spinal canal stenosis (Schizas score > B).
• History of spinal infection.
• Lumbar disc herniation and sciatica.
• Endplate abnormality such as Schmorl's Nodes.
• Previous discal puncture or previous spine surgery.
• IDD with Modic III changes on MRI images.
• Patients not eligible to the intravertebral disc surgery.
• Patients who have the risk to undergo a surgery in the next 6 months.
• Patients with local infusion device/devices for corticosteroids.
• Obesity with body mass index (BMI in Kg/size in m2) greater than 35 (obesity grade II).
• Participation in another clinical trial or treatment with another investigational product within 30 days prior to inclusion in the study.
• Abnormal blood tests: hepatic (alanine aminotransferase [ALT] and/or aspartate aminotransferase [AST] >1.5 × upper limit of normal [ULN]), renal, pancreatic or biliary disease, blood coagulation disorders, anemia or platelet count of <100 × 109/L.
• Pregnant or lactating women, or premenopausal women not using an acceptable form of birth control, are ineligible for inclusion. Contraception will be maintained during treatment and until the end of relevant systemic exposure. Additional pregnancy testing will be performed at the end of relevant systemic exposure. The patients will be required to use contraception from initial treatment administration until 24 months after the last dose of study drug.
• In each case of delayed menstrual period (over 1 month between menstruations), confirmation of absence of pregnancy is strongly recommended. The complete list of contraceptive methods is described in the patient information sheet.
• Positive serology for following infection: Syphilis, HIV, Hepatitis B, or C.
• Contraindication to MRI assessed by the investigator.
• Intolerance or allergy to local anaesthesia.
• Any history of Cancer or immunodeficiency disease.
• Previous transplantation.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Autologous BM-MSC injection; Two interventions: Bone marrow harvesting from the posterior superior iliac crest region; Single injections of a dose of 15 million of autologous BM-MSC each disc affected by IDD (up to 4 discs) via imaging control	Drug: Autologous BM-MSC; intradiscal injection of autologous bone marrow mesenchymal stromal/stem cells; Other Names: Treated
Sham Comparator: Sham Procedure; Two sham procedures: Simulated bone marrow harvesting without insertion into the posterior iliac crest region; Simulated injection under only local anaesthesia without disc injection, without placebo injection.	Other: Sham Procedure; anaesthesia, no disc injection, no placebo injection; Other Names: Sham

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain clinical relief	Pain clinical reduction of at least 40 percent on Visual Analogic Scale (VAS) between baseline and month 12. VAS pain scale ranges from 0 to 100, where 0 represents no pain and 100 represents the worst pain imaginable.	Baseline to month 12
Functional disability index improvement	Functional disability reduction of 40 percent on Oswestry Disability Index (ODI, also known as the Oswestry Low Back Pain Disability Questionnaire) at month 12 compared with baseline. ODI scale ranges from 0 to 50 and allows evaluation of disability (0 - 20 percent: minimal disability; 20 - 40 percent: moderate disability; 40 - 60 percent: severe disability; 60 - 80 percent: crippled; 80 - 100 percent: bed-bound or exaggerating their symptoms).	Baseline to month 12
Work ability improvement	Improvement of 10 percent on Work Ability Index (WAI) at month 12 compared to baseline. The WAI is composed of 7 items and is a validated instrument that assesses the individual work ability of an employee. The total WAI score ranges from 7 to 49 and is calculated by summing up the scores of the 7 items.	Baseline to month 12

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Measure pain relief of the patient	Assessed by Visual Analogic Scale (VAS). VAS pain scale ranges from 0 to 100: where 0 represents no pain and 100 represents the worst pain imaginable.	Baseline, 1, 3 and 6 months
Measure functional disability index of the patient	Assessed by ODI (Oswestry Low Back Pain Disability Questionnaire) scale which ranges from 0 to 50 (0 - 20 percent: minimal disability; 20 - 40 percent: moderate disability; 40 - 60 percent: severe disability; 60 - 80 percent: crippled; 80 - 100 percent: bed-bound or exaggerating their symptoms).	Baseline, 1, 3 and 6 months
Evaluate disability and quality of life evolution of the patient	Assessed by Short Form-36 Health Survey (SF-36) scores which consist of eight 0-100 scaled scores (vitality, physical functioning, bodily pain, general health, perceptions, physical role functioning, emotional role functioning, social role functioning and mental health) where a lower score corresponds to more disability and a higher score corresponds to less disability.	Baseline, 1, 3, 6 and 12 months
Disability and quality of life evolution	Assessed by the patient and the physician on: pain intensity in the lumbar spine (1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = extreme); patient's global assessment of disease activity (1 = very good, 2 = good, 3 = fair, 4 = poor, 5 = very poor); physician's global assessment of disease activity (1 = very good, 2 = good, 3 = fair, 4 = poor, 5 = very poor).	Baseline, 1, 3, 6 and 12 months
Assess rescue painkillers medication	Rescue medication use will be recorded throughout the study duration by a diary file.	Baseline, 1, 3, 6 and 12 months
Structural assessment	Evolution of affected disc(s) by quantitative Magnetic Resonance Imaging (MRI) density measurements with T2 mapping protocol used as an indication of disc fluid and glycosaminoglycans (GAG) content. In addition MRI spectroscopy will provide an assessment of the chemical changes associated with disc degeneration. The "quality" of the patient's lumbar disc will be monitored non invasively using T2 weighted MRI sagittal images and T1spin/echo MRI at the same time points. Lumbar disc grading will be performed in the sagittal T2 weighted images by two experienced physicians independently, who will review each intervertebral disc (from L1-2 to L5-S1) by the modified Pfirrmann criteria.	Baseline, 1, 3, 6 and 12 months
Evaluation of cost	Comparison of medical and non-medical costs between the two groups of patients. Resource used in each arm will be collected in physical units in the eCRF at the clinical centre as follows: Acute care medical hospitalisations related to IDD; Acute care surgical hospitalisations related to IDD; Rehabilitation hospitalisations related to IDD; Analgesics; Work disruption	12 months
Incidence of Adverse Events (AE)	Report of Adverse Events (AE). If the study patients do not spontaneously report any AE occurrence since their last visit, they will be interviewed by the investigator filling a study-specific AE checklist for recording of symptoms and complaints.	Baseline, 1, 3, 6 and 12 months
Assessment of vital signs	During each visit to the study centre, patients will undergo a physical examination with recording of vital signs (temperature, blood pressure, heart rate, height and weight).	Baseline, 1, 3, 6 and 12 months
Evaluation of blood and urine analysis	During each visit to the study centre, patients will undergo blood sampling for assessment of routine lab tests (Haematology and Biochemistry) and urine analysis (dipstick).	Baseline, 1, 3, 6 and 12 months
Analysis of chemical biomarkers for tissue degeneration	Assessment of chemical biomarkers for tissue degeneration through MRI spectroscopy. MRI spectroscopy will be used to provide an assessment of the chemical changes associated with disc degeneration (Zuo et al. 2009).	Baseline, 3, 6 and 12 months

Collaborators and Investigators

• Sponsor: Fondazione Policlinico Universitario Campus Bio-Medico
• Collaborators: Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico; Center for Outcomes Research and Clinical Epidemiology, Italy
• Investigators: Principal Investigator: Gianluca Vadalà, MD, PhD, Campus Bio-Medico University of Rome

Study record dates

Study Major Dates

• Study Start (Actual): November 3, 2019
• Primary Completion (Actual): November 27, 2023
• Study Completion (Actual): November 27, 2023

Study Registration Dates

• First Submitted: January 29, 2021
• First Submitted That Met QC Criteria: February 16, 2021
• First Posted (Actual): February 18, 2021

Study Record Updates

• Last Update Posted (Actual): May 25, 2025
• Last Update Submitted That Met QC Criteria: May 21, 2025
• Last Verified: November 1, 2023

More Information

Terms related to this study

• Keywords: Low back pain; Mesenchymal stem cells; Bone marrow; Spine; Intervertebral disc degeneration
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Bone Diseases; Musculoskeletal Diseases; Spinal Diseases; Back Pain; Low Back Pain; Intervertebral Disc Degeneration
• Other Study ID Numbers: ACTIVE trial_(BRIC2018-ID03); 2019-004476-19 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No