Wedge-Shaped Resection of the Posterior Bony Arch During Open Door Laminoplasty to Prevent Postoperative Motion Limitation

Study Design. Prospective randomized double-arm noninferiority study. Objective. To evaluate an additional surgical procedure (wedge-shaped resection of the cranial portion of the posterior bony arch) during open-door laminoplasty (ODLP), and to compare the outcomes with those of conventional ODLP surgery. Summary of Background Data. In clinical practice, spine surgeons sometimes encounter patients who show bony impingement on lateral radiographs after ODLP; bony impingement may lead to reduced motion of the cervical spine and posterior neck pain. However, this problem has not been well studied, and no methods have been developed to prevent it. Methods. Of total 79 patients, 75 were enrolled and randomly assigned to either group A (additional procedure in ODLP, n = 38) or group B (ODLP alone, n = 37). The primary outcome measure was range of motion (ROM) of the cervical spine. Secondary endpoints included clinical outcomes based on pain intensity, 12-item short form health survey (SF-12), and modified Japanese Orthopedic Association scale; presence of bony impingement on dynamic lateral radiographs; surgical outcomes; and surgery-related complications. Results. ROM of the cervical spine was significantly greater at 6 months (P = 0.04) and 1 year (P = 0.02) postoperative in group A than in group B. Pain intensity at the posterior neck was significantly lower 1 year after surgery in group A than in group B (P = 0.03). In lateral radiographs 1 year after surgery, the presence of posterior bony impingement was 0% in group A and 32.4% in group B (P <0.01). Clinical outcomes and surgery-related complications were similar between groups. Conclusion. Performing wedge-shaped resection of the cranial portion of the posterior bony arch in ODLP surgery can lead to better outcomes than ODLP alone in terms of preservation of cervical ROM, prevention of posterior bony impingement, and amelioration of posterior neck pain. Level of Evidence: 2

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Evolution of Muscles Dysfunction From Myofascial Pain Syndrome Through Cervical Disc-Root Conflict to Degenerative Spine Disease

Study Design. Comparative clinical and neurophysiological study in three groups of patients with general diagnosis of neck pain. Objective. To determine symptoms of muscles dysfunction in patients with myofascial pain syndrome, disc-root conflict, and degenerative changes at cervical spine. Summary and Background Data. The explanation for cervical pain origin should be based on results from chosen clinical and neurophysiological studies in correlation with neuroimaging findings. Methods. Three subgroups of patients (N = 60 each) with certain symptoms were examined. Clinical evaluation included examination of pain intensity in VAS scale, muscle strength in Lovett scale, evaluation of reflexes, Spurling test, assessment of active trigger points (TRPs), and superficial sensory perception. Neurophysiological testing included surface electromyography at rest (rEMG) and during maximal contraction (mcEMG) as well as electroneurography (ENG). Results. The greatest pain intensity with its decentralization phenomenon occurred in patients with disc-root conflict. Significant decrease of muscle strength was detected in trapezius muscle in myofascial pain syndrome subgroup. Weakness of abductor pollicis brevis muscle in patients with disc-root conflict differed them from patients with myofascial pain syndrome (P = 0.05). Patients with disc-root conflict and degenerative spine disease showed differences (P = 0.03) in reflexes evoked from triceps brachii. Positive Spurling symptom was most common (56.7%) in disc-root conflict subgroup. TRPs in trapezius muscle were found in all patients with myofascial pain syndrome. Results of rEMG amplitude measurements differed patients at P = 0.05. Only mcEMG recording from abductor pollicis brevis muscle allows for their clear cut differentiation. ENG studies showed abnormalities in patients with disc-root conflict and degenerative spine disease (P from 0.05 to 0.02). Positive correlation of VAS, TRPs, and rEMG as well as Lovett scores, mcEMG, and ENG results was found. Conclusion. Only applying several clinical and neurophysiological tests together makes it possible to differentiate patients with different etiological reasons of pain at cervical spine. Level of Evidence: 4

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Use of S2-Alar-iliac Screws Associated With Less Complications Than Iliac Screws in Adult Lumbosacropelvic Fixation

Study Design. Retrospective comparative study. Objective. To compare clinical and radiographic outcomes between the S2-alar-iliac (S2AI) and the iliac screw (IS) techniques in the adult population and clarify the clinical strength of S2AI screws. Summary of Background Data. S2AI screws have been described as an alternative method for lumbosacropelvic fixation in place of ISs. The S2AI technique has several advantages with lower prominence, increased ability to directly connect to proximal instrumentation, less extensive dissection of tissue, and enhanced biomechanical strength over the IS technique. However, the clinical significance of these advantages remains unclear. Methods. A single-center retrospective review of patients who underwent lumbosacropelvic fixation yielded 25 IS group patients and 65 S2AI group patients. Baseline demographic information, postoperative complications, pain and functional outcomes, and screw-related outcomes were collected. Results. The S2AI group had lower rates of reoperation (8.8% vs. 48.0%, P < 0.001), surgical site infection (SSI) (1.5% vs. 44.0%, P < 0.001), wound dehiscence (1.5% vs. 36.0%, P < 0.001), and symptomatic screw prominence (0.0% vs. 12.0%, P = 0.02) than the IS group, whereas rates of L5-S1 pseudarthrosis, proximal junctional failure, and sacroiliac joint pain were similar in both groups. Statistically significant pain relief and functional recovery were achieved in both groups without any significant intergroup differences. On multivariate analyses, age [odds ratio (OR) = 0.91, P = 0.004] and S2AI instrumentation (OR = 0.08, P < 0.001) were protective of reoperation, whereas diabetes mellitus (OR = 10.9, P = 0.03) and preoperative diagnosis of tumor (OR = 12.3, P = 0.04) were associated with SSI, and S2AI instrumentation (OR = 0.09, P < 0.001) was protective of SSI. Conclusion. The use of the S2AI technique over the IS technique was an independent predictor of preventing reoperation and SSI, while achieving similar clinical and functional outcomes. Level of Evidence: 4

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Individualized Physical Therapy Is Cost-Effective Compared With Guideline-Based Advice for People With Low Back Disorders

Study Design. A cost-utility analysis within a randomized controlled trial was conducted from the health care perspective. Objective. The aim of this study was to determine whether individualized physical therapy incorporating advice is cost-effective relative to guideline-based advice alone for people with low back pain and/or referred leg pain (≥6 weeks, ≤6 months duration of symptoms). Summary of Background Data. Low back disorders are a burdensome and costly condition across the world. Cost-effective treatments are needed to address the global burden attributable to this condition. Methods. Three hundred participants were randomly allocated to receive either two sessions of guideline-based advice alone (n = 144), or 10 sessions of individualized physical therapy targeting pathoanatomical, psychosocial and neurophysiological factors, and incorporating advice (n = 156). Data relating to health care costs, health benefits (EuroQol-5D) and work absence were obtained from participants via questionnaires at 5, 10, 26, and 52-week follow-ups. Results. Total health care costs were similar for both groups: mean difference $27.03 [95% confidence interval (95% CI): -200.29 to 254.35]. Health benefits across the 12-month follow-up were significantly greater with individualized physical therapy: incremental quality-adjusted life years = 0.06 (95% CI: 0.02–0.10). The incremental cost-effectiveness ratio was $422 per quality-adjusted life year gained. The probability that individualized physical therapy was cost-effective reached 90% at a willingness-to-pay threshold of $36,000. A saving of $1995.51 (95% CI: 143.98–3847.03) per worker in income was realized in the individualized physical therapy group relative to the advice group. Sensitivity and subgroup analyses all revealed a dominant position for individualized physical therapy; hence, the base case analysis was the most conservative. Conclusion. Ten sessions of individualized physical therapy incorporating advice is cost-effective compared with two sessions of guideline-based advice alone for people with low back disorders. Level of Evidence: 2

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Minimally Invasive Surgery Versus Open Surgery Spinal Fusion for Spondylolisthesis: A Systematic Review and Meta-analysis

Study Design. Systematic review and meta-analysis. Objective. Compare minimally invasive surgery (MIS) and open surgery (OS) spinal fusion outcomes for the treatment of spondylolisthesis. Summary of Background Data. OS spinal fusion is an interventional option for patients with spinal disease who have failed conservative therapy. During the past decade, MIS approaches have increasingly been used, with potential benefits of reduced surgical trauma, postoperative pain, and length of hospital stay. However, current literature consists of single-center, low-quality studies with no review of approaches specific to spondylolisthesis only. Methods. This first systematic review of the literature regarding MIS and OS spinal fusion for spondylolisthesis treatment was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for article identification, screening, eligibility, and inclusion. Electronic literature search of Medline/PubMed, Cochrane, EMBASE, and Scopus databases yielded 2489 articles. These articles were screened against established criteria for inclusion into this study. Results. A total of five retrospective and five prospective articles with a total of 602 patients were found. Reported spondylolisthesis grades were I and II only. Overall, MIS was associated with less intraoperative blood loss (mean difference [MD], −331.04 mL; 95% confidence interval [CI], −490.48 to −171.59; P < 0.0001) and shorter length of hospital stay (MD, −1.74 days; 95% CI, −3.04 to −0.45; P = 0.008). There was no significant difference overall between MIS and OS in terms of functional or pain outcomes. Subgroup analysis of prospective studies revealed MIS had greater operative time (MD, 19.00 minutes; 95% CI, 0.90 to 37.10; P = 0.04) and lower final functional scores (weighted MD, −1.84; 95% CI, −3.61 to −0.07; P = 0.04) compared with OS. Conclusion. Current data suggests spinal fusion by MIS is a safe and effective approach to treat grade I and grade II spondylolisthesis. Moreover, although prospective trials associate MIS with better functional outcomes, longer-term and randomized trials are warranted to validate any association found in this study. Level of Evidence: 2

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Surgical Management of the Pregnant Patient With Lumbar Disc Herniation in the Latter Stage of the Second Trimester

Study Design. Case report. Objective. To report on a pregnant woman successfully treated with microendoscopic discectomy in the left lateral position under general anesthesia at 24-week gestation. Summary of Background Data. Treatment for lumbar disc herniation in pregnant women poses a particular challenge due to the complexity of the clinical situation. Review of the literature emphasizes timely diagnosis with adequate management specific for each gestational period. A surgical approach mandates consideration of the physiologic parameters of pregnancy and the effects of these stressors on the fetus. Methods. A 38-year-old primigravid woman presented with persistent and incapacitating low back and left leg pain. Magnetic resonance imaging demonstrated a herniated disc at L4-5 with a severely compressed left L5 nerve root. Symptoms were resistant to conservative treatment (acetaminophen; 1200 mg/day) and nerve root block with corticosteroids (1 mg/0.5 mL of betamethasone plus 0.5 mL of 1% lidocaine) provided only transient pain relief. Operative management with surgical discectomy was discussed. Anesthesiologists, obstetricians, and neonatologists were consulted for preoperative planning, focusing on appropriate anesthesia, ideal positioning for surgical access, and provision for emergent fetal care. Surgery was ultimately performed in the left lateral position, in contrast to the oft-used prone position. Microendoscopic discectomy was performed under general anesthesia at 24-week gestation. Results. The patient experienced complete relief from pain after surgical intervention and delivered a healthy baby at 39-week gestation after normal labor. Our methods, used in accordance with our preoperative simulation, resulted in a satisfactory outcome for both mother and child. Conclusion. Although previously published cases noted the safety of operating in the prone position under epidural anesthesia, we performed minimally invasive microendoscopic discectomy in the left lateral position in combination with general anesthesia and found that this is a safe and preferable alternative for pregnant patients in the latter stage of the second trimester. Level of Evidence: N/A

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The value of prognostic screening for patients with low back pain in secondary care

Prognostic screening in patients with low back pain (LBP) offers a practical approach to guiding clinical decisions. Whether screening is helpful in secondary care is unclear. This prospective cohort study in adults with LBP placed on outpatient clinic waiting lists, compared the performance of the short-form Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ), the PICKUP Tool (PICKUP) and the STarT Back Tool (SBT). We assessed predictive validity for outcome at 4-month follow-up, by calculating estimates of discrimination, calibration and overall performance.

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Trunk muscle activity during different variations of the supine plank exercise

Exercises providing neuromuscular challenges of the spinal muscles are desired for core stability, which is important for workers with heavy manual labour as well as people recovering from back pain.

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The development of a shoulder specific left/right judgement task: Validity & reliability

Disruption of cortically-held working body schema has been associated with a variety of pain conditions. A motor imagery technique - the left right judgement task (LRJT) - has been used as an indirect assessment of the integrity of the working body schema. To date there is no LRJT specifically designed to investigate the body schema of persons with shoulder pain.

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How Receptive Are Patients With Late Stage Cancer to Rehabilitation Services and What Are the Sources of Their Resistance?

Effectiveness of a Treatment Involving Soft Tissue Techniques and/or Neural Mobilization Techniques in the Management of Tension-Type Headache

Postrehabilitation Functional Improvements in Patients With Inflammatory Myopathies: The Results of a Randomized Controlled Trial

Nested Cohort Study to Identify Characteristics That Predict Near-Term Disablement From Lung Cancer Brain Metastases

Is Interferential Current Before Pilates Exercises More Effective Than Placebo in Patients With Chronic Nonspecific Low Back Pain?

Change in “Self-as-Context” (“Perspective-taking”) Occurs in Acceptance and Commitment Therapy for People with Chronic Pain and is Associated with Improved Functioning

Acceptance and Commitment Therapy (ACT) is based on the Psychological Flexibility (PF) model, which includes a therapeutic process, referred to as “self-as-context” (SAC). This study investigates whether ACT is associated with an effect on SAC and whether this effect is linked to treatment outcomes in people with chronic pain. 412 adults referred to a pain management center participated in the study. Participants completed measures of treatment processes (SAC, pain acceptance) and outcomes (pain-related interference, work and social adjustment, depression) before treatment, upon completion of treatment, and at nine-month follow-up.

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Longitudinal and temporal associations between daily pain and sleep patterns after major pediatric surgery

Around 20% of children develop persistent pain after major surgery. Sleep disruption has been implicated as a predictor of children’s acute postsurgical pain. However, perioperative sleep patterns have not been longitudinally assessed, and the role of sleep in persistence of postsurgical pain has not been explored. We aimed to examine sleep patterns over 4 months in children having major surgery, and temporal relationships between daily sleep and pain. Sixty children age 10-18 (M=14.7) years having major surgery completed 7 days of actigraphy sleep monitoring (sleep duration, efficiency), twice daily electronic diaries (sleep quality, pain intensity, medication use), and validated questionnaires at pre-surgery, 2-weeks, and 4-months post-surgery.

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Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review

Cervical spinal manipulation (CSM) and cervical mobilization are frequently used in patients with neck pain and headache. Pre-manipulative cervical instability and arterial integrity tests appear to be unreliable in identifying patients at risk for adverse events. It would be valuable if patients at risk could be identified by specific characteristics during the preliminary screening.Objective was to identify characteristics of 1) patients, 2) practitioners, 3) treatment process and 4) adverse events (AE) occurring after CSM or cervical mobilization.

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Shared decision making in low risk chest pain: looking ahead

We commend Hess and colleagues for studying shared decision making,1 which is best suited for forks in the road, where neither course is clearly superior.23 This currently seems to be the case for...

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Predicting recovery in patients with acute low back pain: A Clinical Prediction Model

Abstract

Background

There is substantial variability in the prognosis of acute low back pain (LBP). The ability to identify the probability of individual patients recovering by key time points would be valuable in making informed decisions about the amount and type of treatment to provide. Predicting recovery based on presentation 1-week after initially seeking care is clinically important and may be more accurate than predictions made at initial presentation. The aim of this study was to predict the probability of recovery at 1-week, 1-month and 3-months after 1-week review in patients who still have LBP 1-week after initially seeking care.

Methods

The study sample comprised 1070 patients with acute LBP, with a pain score of ≥2 1-week after initially seeking care. The primary outcome measure was days to recovery from pain. Ten potential prognostic factors were considered for inclusion in a multivariable Cox regression model.

Results

The final model included duration of current episode, number of previous episodes, depressive symptoms, intensity of pain at 1-week, and change in pain over the first week after seeking care. Depending on values of the predictor variables, the probability of recovery at 1-week, 1-month and 3-months after 1-week review ranged from 4% to 59%, 19% to 91% and 30% to 97%, respectively. The model had good discrimination (C = 0.758) and calibration.

Conclusions

This study found that a model based on five easily collected variables could predict the probability of recovery at key time points in people who still have LBP 1-week after seeking care.

Significance

A clinical prediction model based on five easily collected variables was able to predict the likelihood of recovery from an episode of acute LBP at three key time points. The model had good discrimination (C = 0.758) and calibration.

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Endocannabinoid activation of CB1 receptors contributes to long-lasting reversal of neuropathic pain by repetitive spinal cord stimulation

Abstract

Background

Spinal cord stimulation (SCS) has been shown to be effective in the management of certain neuropathic pain conditions, however, the underlying mechanisms are incompletely understood. In this study, we investigated repetitive SCS in a rodent neuropathic pain model, revealing long-lasting and incremental attenuation of hyperalgesia and a mechanism of action involving endocannabinoids.

Method

Animals were implanted with monopolar electrodes at the time of partial sciatic nerve injury. Dorsal columns at spinal segments T12/13 were stimulated 3 days later (early SCS), and again at day 7 (late SCS) using low-frequency parameters. Hypersensitivity to cutaneous mechanical stimuli was assessed using von Frey filaments. Pharmacological agents, selected to identify endocannabinoid and opioid involvement, were administered intraperitoneally, 10 min before SCS.

Results

Early SCS caused partial reversal of mechanical hypersensitivity with corresponding changes in the biomarker of central sensitization, [phospho-Tyr¹⁴⁷²]-GluN2B. The partial reversal of hyperalgesia by early SCS was amplified by co-administration of LY 2183240, an inhibitor of endocannabinoid reuptake/breakdown. This amplification was inhibited by a CB₁R antagonist, AM251, but not by a CB₂R antagonist, AM630. Early SCS-induced reversal of hyperalgesia was attenuated by naloxone, indicating a role for opioids. Late SCS resulted in an incremental level of reversal of hyperalgesia, which was inhibited by AM251, but not by CB₂ or opioid receptor antagonists.

Conclusion

The endocannabinoid system, and in particular the CB₁R, plays a pivotal role in the long-lasting and incremental reversal of hyperalgesia induced by repetitive SCS in a neuropathic pain model.

Significance

Alternative parameters for repetitive spinal cord stimulation (SCS) at 25/10 Hz elicit particularly long-lasting and incremental reversal of hyperalgesia in a neuropathic pain model through a mechanism involving endocannabinoids.

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The prevalence and impact of chronic neuropathic pain on daily and social life: A nationwide study in a Japanese population

Abstract

Background

This study marks the first epidemiological evaluation of the prevalence and burden of chronic neuropathic pain (NeP) in an Asian population. The objective of this nationwide cross-sectional study was to identify the characteristics of individuals with NeP, detect the NeP features that affect their quality of life (QOL), and demonstrate the negative effects of NeP on social and daily living as well as comorbidities including depression, anxiety and sleep disorders.

Methods

We mailed a cross-sectional, population-based epidemiological survey to a random nationwide sample of 10,000 Japanese adults over 20 years old.

Results

The response rate was 54.4% (2445 men, 2992 women; mean age, 53.4 years). Prevalence of chronic pain was 16.6%, and prevalence of NeP was 3.2% as detected by the PainDETECT. Participants with NeP showed significantly lower quality of life according to scores on the EuroQol-5 Dimensions scale (p < 0.001), higher levels of psychological distress on the Kessler 6-item psychological distress scale (p < 0.001), poorer sleep quality (p < 0.001), and more workdays lost (p < 0.001) than did participants without NeP. Linear regression modelling showed that widespread pain, thermal hyperalgesia and pressure-induced pain had strong associations with lower QOL, with regression coefficients of −0.046 (p < 0.001), −0.038 (p < 0.001), and −0.040 (p < 0.001), respectively.

Conclusions

This study is the first to report the prevalence of NeP in an Asian population using a validated questionnaire. This study provides compelling evidence that chronic NeP is more strongly associated with poorer QOL, mental health and social well-being than CP without a neuropathic component.

Significance

This population-based nationwide epidemiological study revealed the prevalence, characteristics, and negative effects of chronic pain with neuropathic components in Asian society. The prevalence of neuropathic pain was 3.2% with PainDETECT.

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Verbal instructions influence pain thresholds assessment: A study using manual and electronic mechanical stimulators

Abstract

Background

Quantitative sensory testing (QST) relies on psychophysical techniques and instructions to test subjects. This study examined the effect of different verbal instructions for mechanical pain thresholds (MPTs) using two different stimulation techniques; weighted pinprick stimulators and an electronic von Frey device (EvF). The test–retest reliability and within session variability in the MPTs for each verbal instruction were compared in addition.

Methods

Sixteen healthy volunteers participated. The MPTs with two different verbal instructions (pinprick and pain) were evaluated with two different stimulation techniques at three test sites: on the skin of the right cheek (face), on the buccal gingival mucosa of the right upper premolar region (gingiva) and on the tip of the tongue (tongue). The exact same protocol was repeated 1–2 weeks later for test–retest reliability.

Results

The MPT values with pain instruction were significantly higher than the values with the pinprick instruction for all sites and both stimulation techniques (p < .001). The absolute values of MPT were affected by instruction differences but it did not seem to have a major impact on reliability, and there were no significant differences in within session variability (p > .079) between the two different verbal instructions (pinprick and pain).

Conclusions

The specific wording of standardized QST instructions resulted in significant differences in MPT values regardless of which of the two stimulation techniques were used; pinprick stimulators or EvF. This emphasizes the importance of careful standardization of QST instructions in addition to standardization of the stimulus application.

Significance

Quantitative sensory testing (QST) is a widely accepted tool for somatosensory testing and the reliability and variability in the QST test battery has been found to be acceptable. Changing minor details in the wording of standardized QST verbal instructions resulted in significant differences in mechanical pain thresholds. This emphasizes the importance of careful standardization of QST instructions in addition to standardization of the stimulus application.

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Measuring expectation of pain: Contingent negative variation in placebo and nocebo effects

Abstract

Background

Expectation is an important mechanism underlying placebo response. Here, we analysed expectation of placebo hypoalgesia and nocebo hyperalgesia by using, for the first time, the contingent negative variation (CNV), also known as expectancy wave.

Methods

Subjects were presented a green or red cue followed by a train of either non painful or painful electrical stimuli, and expected hypoalgesia after the green and hyperalgesia after the red cue. In experiment 1, expectation was reinforced using a conditioning procedure whereby the green and red cues were paired with non painful and painful stimuli, respectively (acquisition). In a second session (test) the intensity of the stimuli was kept constant, regardless of cue. In experiment 2 no conditioning was performed and participants expected an altered pain perception indicated by the visual cues. CNV mean amplitude, time necessary to stop the train of stimuli (reaction time) and pain ratings were measured.

Results

A difference in pain perception occurred when electrical stimuli followed the presentation of the green cue compared to the red in the test session, whereas reaction times showed no changes. The same difference occurred in the early CNV component, related to cognitive stimulus anticipation, whereas the late CNV component, related to motor preparation, did not change. Moreover, these differences in pain perception and CNV amplitude were less robust in the experiment 2.

Conclusion

Placebo hypoalgesia and nocebo hyperalgesia differently affect sensory (pain perception) and motor components (pain avoidance) of pain. Furthermore, CNV is an electrophysiological objective measure capable of dissecting these components.

Significance

Dissection of placebo hypoalgesia, differentiating the sensory component (pain perception) from the motor component (pain avoidance). Study of these components using the contingent negative variation (CNV) as an electrophysiological objective measure.

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Reduced laser-evoked potential habituation detects abnormal central pain processing in painful radiculopathy patients

Abstract

Background

Repetitive painful laser stimuli lead to physiological laser-evoked potential (LEP) habituation, measurable by a decrement of the N2/P2 amplitude. The time course of LEP-habituation is reduced in the capsaicin model for peripheral and central sensitization and in patients with migraine and fibromyalgia. In the present investigation, we aimed to assess the time course of LEP-habituation in a neuropathic pain syndrome, i.e. painful radiculopathy.

Methods

At the side of radiating pain, four blocks of 25 painful laser stimuli each were applied to the ventral thigh at the L3 dermatome in 27 patients with painful radiculopathy. Inclusion criteria were (1) at least one neurological finding of radiculopathy, (2) low back pain with radiation into the foot and (3) a positive one-sided compression of the L5 and/or S1 root in the MRI. The time course of LEP-habituation was compared to 20 healthy height and age matched controls. Signs of peripheral (heat hyperalgesia) and central sensitization (dynamic mechanical allodynia and hyperalgesia) at the affected L5 or S1 dermatome were assessed with quantitative sensory testing.

Results

Painful radiculopathy patients showed decreased LEP-habituation compared to controls. Patients with signs of central sensitization showed a more prominent LEP-habituation decrease within the radiculopathy patient group.

Conclusions

Laser-evoked potential habituation is reduced in painful radiculopathy patients, which indicates an abnormal central pain processing. Central sensitization seems to be a major contributor to abnormal LEP habituation. The LEP habituation paradigm might be useful as a clinical tool to assess central pain processing alterations in nociceptive and neuropathic pain conditions.

Significance

Abnormal central pain processing in neuropathic pain conditions may be revealed with the laser-evoked potential habituation paradigm. In painful radiculopathy patients, LEP-habituation is reduced compared to healthy controls.

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Acupuncture and electro-acupuncture for people diagnosed with subacromial pain syndrome: A multicentre randomized trial

Abstract

Background

Musculoskeletal disorders have been identified globally as the second most common healthcare problem for ‘years lived with disability’, and of these shoulder conditions are amongst the most common, frequently associated with substantial pain and morbidity. Exercise and acupuncture are often provided as initial treatments for musculoskeletal shoulder conditions but their clinical effectiveness is uncertain. This study compared group exercise with group exercise plus either acupuncture or electro-acupuncture in patients with subacromial pain syndrome.

Methods

Two hundred and twenty-seven participants were recruited to a three-arm parallel-group randomized clinical trial. The primary outcome measure was the Oxford Shoulder Score. Follow-up was post treatment, and at 6 and 12 months. Between-group differences (two comparisons: the exercise group versus each of the acupuncture groups) were analysed at 6 months. A similar comparison across all follow-up time points was also conducted. Data were analysed on intention-to-treat principles with imputation of missing values.

Results

Treatment groups were similar at baseline, and all treatment groups demonstrated an improvement over time. Between-group estimates at 6 months were, however, small and non-significant, for both of the comparisons. The analyses across all follow-up time points yielded similar conclusions. There was a high rate of missing values (22% for the Oxford Shoulder Score). A sensitivity analysis using complete data gave similar conclusions to the analysis with missing values imputed.

Conclusions

In the current investigation, neither acupuncture nor electro-acupuncture were found to be more beneficial than exercise alone in the treatment of subacromial pain syndrome. These findings may support clinicians with treatment planning.

Significance

Shoulder pain is common and associated with substantial morbidity. Acupuncture is a popular treatment for shoulder pain. The findings suggest that acupuncture and electro-acupuncture offer no additional benefit over exercise in the treatment of shoulder pain of musculoskeletal origin.

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Pain-evoked trunk muscle activity changes during fatigue and DOMS

Abstract

Background

Muscle pain may reorganize trunk muscle activity but interactions with exercise-related muscle fatigue and delayed onset muscle soreness (DOMS) is to be clarified.

Methods

In 19 healthy participants, the trunk muscle activity during 20 multi-directional unpredictable surface perturbations were recorded after bilateral isotonic saline injections (control) and during unilateral and bilateral hypertonic saline-induced low back pain (LBP) in conditions of back muscle fatigue (Day-1) and DOMS (Day-2). Pain intensity and distribution were assessed by visual analogue scale (VAS) scores and pain drawings. The degree of fatigue and DOMS were assessed by Likert scale scores. Root-mean-square electromyographic (RMS-EMG) signals were recorded post-perturbation from six bilateral trunk muscles and the difference from baseline conditions (Delta-RMS-EMG) was extracted and averaged across abdominal and back muscles.

Results

In DOMS, peak VAS scores were higher during bilateral control and bilateral saline-induced pain than fatigue (p < 0.001) and during bilateral compared with unilateral pain (p < 0.001). The saline-induced pain areas were larger during DOMS than fatigue (p < 0.01). In response to surface perturbations during fatigue and DOMS, the back muscle Delta-RMS-EMG increased during bilateral compared with unilateral pain and control injections (p < 0.001) and decreased during unilateral pain compared with control injections (p < 0.04). In DOMS compared with fatigue, the post-perturbation Delta-RMS-EMG in back muscles was higher during bilateral pain and lower during unilateral pain (p < 0.001). The abdominal Delta-RMS-EMG was not significantly affected.

Conclusion

Facilitated and attenuated back muscle responses to surface perturbations in bilateral and unilateral LBP, respectively, was more expressed during exercise-induced back muscle soreness compared with fatigue.

Significance

Back muscle activity decreased during unilateral and increased during bilateral pain after unpredictable surface perturbations during muscle fatigue and DOMS. Accumulation effects of DOMS on pain intensity and spreading and trunk muscle activity after pain-induction.

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Haemosuccus pancreaticus

A 57 year old man presented with epigastric pain and episodes of melaena, three months after a percutaneous pancreatic biopsy for suspected cancer. Abdominal computed tomography showed active...

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Diagnosis and management of an acute knee injury

A 47 year old presented to the emergency department with a severely painful left knee after she was hit while skiing by a fellow skier who approached at high speed from behind. The pain occurred...

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Patient-Induced Reaction Forces and Moments Are Influenced by Variations in Spinal Manipulative Technique

Study Design. An in vivo biomechanical study. Objective. The aim of the present study was to quantify and compare the reaction loads for two spinal manipulation therapy (SMT) procedures commonly used for low back pain using a biomechanical computer model. Summary of Background Data. Contemporary computer-driven rigid linked-segment models (LSMs) have made it feasible to analyze low back kinetics and kinematics during various activities including SMT procedures. Currently, a comprehensive biomechanical model analyzing actual differences in loading effects between different SMT procedures is lacking. Methods. Twenty-four healthy/asymptomatic participants received a total of six SMT applications, representing all combinations of two similar SMT procedures within three patient hip flexion angles. All contact forces, patient torso kinematics, and inertial properties were entered into a dynamic three-dimensional LSM to calculate lumbar reaction forces and moments. Peak net applied force along with the maximums, minimums, and ranges for each component of the three-dimensional reaction force and moment vectors during each SMT procedure was analyzed. Results. One specific SMT technique (lumbar spinous pull) produced greater maximum anterior-posterior reaction force and both lateral bending and axial twisting reaction moments compared to the other technique (lumbar push procedure [all P ≤ 0.034]). SMT trials without hip flexion had lower maximum medial-lateral reaction force and range compared to those with 45 and 90 degrees of hip flexion (all P ≤ 0.041). There were no interactions between procedure and hip angle for any of the dependent measurements. Conclusion. The technique used to apply SMT and the participant's initial hip orientation induced significantly different actions on the low back. These findings and future research can improve patient outcomes and safety by informing clinicians on how to best use SMT given specific types of low back pain. Level of Evidence: 2

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Accelerated Discharge Protocol for Posterior Spinal Fusion Patients With Adolescent Idiopathic Scoliosis Decreases Hospital Postoperative Charges 22%

Study Design. A retrospective study of consecutive patients. Objective. The purpose of this study was to determine implementing an accelerated protocol could decrease our average hospital stay and what impact this had on postoperative pain management. Summary of Background Data. To our knowledge, no prior studies have reviewed the effect of an accelerated discharge protocol on postoperative pain control for adolescent idiopathic scoliosis (AIS) following posterior spinal fusion. Methods. This is a retrospective review of all consecutive patients undergoing posterior spinal fusion (PSF) for AIS before (June 1, 2008–May 31, 2013 = traditional protocol) and after (June 1, 2013–October 22, 2014 = accelerated protocol) protocol implementation. Subjective response to the FACES Pain Intensity scale was collected for each postoperative day while in the hospital by the nursing staff. Results. There were 194 patients in the traditional pathway and 90 patients in the accelerated pathway. No significant differences in age at surgery, sex, or number of levels fused were present between the groups. Patients managed under the accelerated discharge had an average hospital stay of 3.7 days compared with 5.0 days for the traditional discharge (P < 0.001). There was no increased incidence of wound complications between the two groups [3.6% (7/194) vs. 3.3% (3/90), P = 0.91] or readmission [1.5% (3/194) vs. 4.4% (4/90), P = 0.213]. Hospital charges for postoperative care were significantly less in the accelerated discharge group than in the traditional group ($18,360 vs. $23,640, P < 0.0001). This corresponded to a 22% ($5280/$23,640) decrease in postoperative hospital charges. Patients had a small (<1 point change on FACES pain scale) but statistically significant increase in pain on postoperative days 2, 3, and 4 (P = 0.0001, P = 0.0079, P = 0.0076). Conclusion. Accelerated discharge following PSF for AIS was associated with a 22% decrease in hospital charges in the postoperative period. Level of Evidence: 4

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Do Lumbar Decompression and Fusion Patients Recall Their Preoperative Status?: A Cohort Study of Recall Bias in Patient-Reported Outcomes

Study Design. Prospective cohort study. Objective. To characterize the accuracy of patient recollection of preoperative symptoms after lumbar spine surgery. Summary of Background Data. Although patient-reported outcomes have become important in the evaluation of spine surgery patients, the accuracy of patient recall remains unknown. Methods. Patients undergoing lumbar decompression with or without fusion were enrolled. Back and leg Numeric Pain Scores and Oswestry Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at a minimum of 1 year after surgery. Actual and recalled scores were compared using paired t tests and relations were quantified using Pearson correlation coefficients. Multivariable linear regression was used to identify factors that affected recollection. Results. Sixty-two patients with a mean age of 66.1 years were included. Compared to their preoperative scores, patients showed significant improvement in back pain (mean difference [MD] = −3.2, 95% CI −4.0 to −2.4), leg pain (MD −3.3, 95% CI −4.3 to −2.2), and disability (MD −25.0%, 95% CI −28.7 to −19.6). Patient recollection of preoperative status was significantly more severe than actual for back pain (MD +2.3, 95% CI 1.5–3.2), leg pain (MD +1.8, 95% CI 0.9–2.7), and disability (MD +9.6%, 95% CI 5.6–14.0). No significant correlation between actual and recalled scores with regards to back (r = 0.18) or leg (r = 0.24) pain and only moderate correlation with disability (r = 0.44) were seen. This was maintained across age, sex, and time between date of surgery and recollection. More than 40% of patients switched their predominant symptom from back pain to leg pain or leg pain to back pain on recall. Conclusion. Relying on patient recollection does not provide an accurate measure of preoperative status after lumbar spine surgery. Recall bias indicates the importance of obtaining true baseline scores and patient-reported outcomes prospectively and not retrospectively. Level of Evidence: 2

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Surgical Management of Civilian Gunshot-Induced Spinal Cord Injury: Is It Overutilized?

Study Design. Retrospective chart review. Objective. Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort. Summary of Background Data. CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated. Methods. Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0–10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups. Results. Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients. Conclusion. We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs. Level of Evidence: 3

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Seeing an embodied virtual hand is analgesic contingent on co-location

Seeing one’s own body has been reported to have analgesic properties. Analgesia has also been described when seeing an embodied virtual body co-located with the real one. However, there is a controversy regarding whether this effect holds true when seeing an illusory-owned body part, such as during the rubber-hand illusion. A critical difference between these paradigms is the distance between real and surrogate body part. Co-location of real arm and surrogate is possible in an immersive virtual environment, but not during illusory ownership of a rubber arm.

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Trajectory of Improvement in Children and Adolescents with Chronic Migraine: Results from the Cognitive Behavioral Therapy and Amitriptyline Trial

We compared headache frequency trajectories between clinical trial participants who received cognitive behavioral therapy plus amitriptyline (CBT+A) or headache education plus amitriptyline (HE+A) to determine if there was differential time course of treatment response between the groups. 135 patients (age 10-17) diagnosed with chronic migraine participated, attending 8 one-hour one-on-one CBT or HE sessions with a trained psychologist for 8 weekly sessions, 2 sessions at weeks 12 and 16, and a post-treatment visit at week 20.

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Reliability and minimal detectable change of a modified passive neck flexion test in patients with chronic nonspecific neck pain and asymptomatic subjects

The Passive Neck Flexion Test (PNFT) can diagnose meningitis and potential spinal disorders. Little evidence is available concerning the use of a modified version of the PNFT (mPNFT) in patients with chronic nonspecific neck pain (CNSNP).

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Cervical traction therapy with and without neck support: A finite element analysis

Cervical traction is commonly used for treating neck pain. However, few studies have investigated the biomechanical impact such traction has on soft tissues.

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Bridging the evidence-practice gaps in manual therapy: Getting the balance right

Figg-Latham J, Rajendran D, Quiet dissent: The attitudes, beliefs and behaviours of UK osteopaths who reject low back pain guidance – A qualitative study, Manual Therapy (2016), http://ift.tt/2iFQJha.

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Linguistic Indicators of Pain Catastrophizing in Patients with Chronic Musculoskeletal Pain

The present study examined markers of pain catastrophizing in the word use of patients with chronic pain. Patients (n = 71) completed the Pain Catastrophizing Scale and wrote about their life with pain. Quantitative word count analysis examined whether the essays contained linguistic indicators of catastrophizing. Bivariate correlations showed that catastrophizing was associated with greater use of first person singular pronouns, such as “I” (r = .27, p≤ .05) and pronouns referencing other people (r = 28, p≤ .05).

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Gaps in the Public’s Knowledge about Chronic Pain: Representative Sample of Hispanic Residents from Five States

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a five-state, population-based sample of Hispanics aged 35-75 without chronic pain, representing over 8.8 million persons. A web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (n=346), mean age was 52.0 (+10.6), 54% were women, 53% preferred Spanish, and 39% did not graduate from high school.

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Patient-Reported Outcomes and Opioid Use In Outpatients with Chronic Pain

The Weill Cornell Medical College (WCMC) Pain Registry database contains patient characteristics, treatments, and outcomes for a prospective cohort of 1159 chronic pain patients who were seen at the WCMC Pain Medicine outpatient clinic from 7/08/2011 to 12/10/2014. Patients aged 45-64 comprised 43% followed by age >=65 at 37%. Fifty-eight percent were female. Average pain intensity (Brief Pain Inventory) was reported as mild by 22.3% of patients, moderate by 34.7%, and severe by 43.0%. For each pain intensity category, patient’s report of average percent pain relief and health state (EQ-5D) was inversely related to average pain intensity category, while measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category.

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A painful swollen knee after a fall

Correspondence to: sseewoonarain@gmail.comA 27 year old man stumbled down a step and twisted his left knee. He felt immediate severe pain in the knee and was unable to weight bear. On examination he...

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