Carl Noe

Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: A one-year prospective study

In an attempt to prevent acute low-back pain from becoming a chronic disability problem, an earlier study developed a statistical algorithm which accurately identified those acute low-back pain patients who were at high risk for developing such chronicity. The major goal of the present study was to evaluate the clinical effectiveness of employing an early intervention program with these high-risk patients in order to prevent the development of chronic disability at a 1-year follow-up. Approximately 700 acute low-back pain patients were screened for their high-risk versus low-risk status. On the basis of this screening, high-risk patients were then randomly assigned to one of two groups: a functional restoration early intervention group (n = 22), or a nonintervention group (n = 48). A group of low-risk subjects (n = 54) who did not receive any early intervention was also evaluated. All these subjects were prospectively tracked at 3-month intervals starting from the date of their initial evaluation, culminating in a 12-month follow-up. During these follow-up evaluations, pain disability and socioeconomic outcomes (such as return-to-work and healthcare utilization) were assessed. Results clearly indicated that the high-risk subjects who received early intervention displayed statistically significant fewer indices of chronic pain disability on a wide range of work, healthcare utilization, medication use, and self-report pain variables, relative to the high-risk subjects who do not receive such early intervention. In addition, the high-risk nonintervention group displayed significantly more symptoms of chronic pain disability on these variables relative to the initially low-risk subjects. Cost-comparison savings data were also evaluated. These data revealed that there were greater cost savings associated with the early intervention group versus the no early intervention group. The overall results of this study clearly demonstrate the treatment- and cost-effectiveness of an early intervention program for acute low-back pain patients.

Anesthesia for ophthalmic surgery in the elderly: the effects of clonidine on intraocular pressure, perioperative hemodynamics, and anesthetic requirement.

The effects of clonidine on intraocular pressure and perioperative cardiovascular variables were studied by a randomized double blind design in 80 elderly patients (ASA physical status I-III) scheduled for elective ophthalmic surgery under general anesthesia (GA) and local anesthesia (LA). Group 1 (n = 40), the control group, received diazepam po (0.1 mg·kg-1) 90–120 min prior to arrival to the operating room. Group 2 (n = 40) received clonidine po approximately 5 μg ± kg-1 po at the same time. Each group was divided into subgroups of 20 patients each to be managed with GA (GA subset) or LA (LA subset). Ninety to 120 minutes after the premedication, a large decrease in IOP from 20 ± 3 to 12 ± 3 mmHg (P < 0.01) and a small but significant reduction of both systolic and diastolic BP and HR were observed in patients receiving clonidine, while no changes occurred in controls. In the patients managed with GA, clonidine effectively prevented IOP rise and attenuated the associated cardiovascular response (P < 0.01) following laryngoscopy and tracheal intubation, and significantly reduced intraoperative cardio vascular lability and anesthetic requirement for isoflurane (P < 0.05) and for fentanyl (P < 0.01). In patients managed with LA, intraoperative systolic (P < 0.01) and diastolic BP and HR variability (P < 0.05) were significantly lower in patients receiving clonidine as compared to controls. Intraoperatively, a significantly higher incidence of hypertension (P < 0.01) and tachycardia (P < 0.05) were respectively observed in the LA subset and GA subset of the controls when contrasted with the corresponding subset of those receiving clonidine. Moreover, clonidine was more effective than diazcpam as a premedicaltion; in fact, satisfactory intraoperative sedation and cardiovascular stability were observed in 85% of the patients who received clonidine, and in 50% of those patients who did not receive clonidine (P < 0.01). Thus, clonidine may represent a useful adjunct in the management of the aged patient in the setting of ophthalmic surgery.

Effect of the Duration of Electrical Stimulation on the Analgesic Response in Patients with Low Back Pain

BACKGROUND Electrical stimulation of peripheral nerves produces acute analgesic effects. This randomized, sham-controlled, crossover study was designed to evaluate the effect of differing durations of electrical stimulation on the analgesic response to percutaneous electrical nerve stimulation in 75 consenting patients with low back pain. METHODS All patients received electrical stimulation for four different time intervals (0, 15, 30, and 45 min) in a random sequence over the course of an 11-week study period. All active percutaneous electrical nerve stimulation treatments were administered using alternating frequencies of 15 and 30 Hz three times per week for 2 consecutive weeks. The prestudy assessments included the health status survey short form questionnaire and 10-cm visual analog scale scores for pain, physical activity, and quality of sleep, with 0 being the best and 10 being the worst. The pain scoring was repeated 5-10 min after each 60-min study session and 24 h after the last treatment session with each of the four methods. The daily oral analgesic requirements were assessed during each of the four treatment blocks. At the end of each 2-week treatment block, the questionnaire was repeated. RESULTS Electrical stimulation using percutaneously placed needles produced short-term improvements in the visual analog scale pain, physical activity, and quality of sleep scores, and a reduction in the oral analgesic requirements. The 30-min and 45-min durations of electrical stimulation produced similar hypoalgesic effects (48+/-21% and 46+/-19%, respectively) and were significantly more effective than either 15 min (21+/-17%) or 0 min (10+/-11%). The 30- and 45-min treatments were also more effective in improving physical activity and sleep scores over the course of the 2-week treatment period. In contrast to the sham treatment (0 min), the health status survey short form revealed that electrical stimulation for 15 to 45 min three times per week for 2 weeks improved patient function. CONCLUSION The recommended duration of electrical stimulation with percutaneous electrical nerve stimulation therapy is 30 min.

The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain

UNLABELLED Low back pain (LBP) is one of the most common medical problems in our society. Increasingly, patients are turning to nonpharmacologic analgesic therapies such as percutaneous electrical nerve stimulation (PENS). We designed this sham-controlled study to compare the effect of three different frequencies of electrical stimulation on the analgesic response to PENS therapy. Sixty-eight consenting patients with LBP secondary to degenerative lumbar disc disease were treated with PENS therapy at 4 Hz, alternating 15 Hz and 30 Hz (15/30 Hz), and 100 Hz, as well as sham-PENS (0 Hz), according to a randomized, cross-over study design. Each treatment was administered for a period of 30 min three times per week for 2 wk. The pre- and posttreatment assessments included the health status survey short form and visual analog scales for pain, physical activity, and quality of sleep. After receiving all four treatments, patients completed a global assessment questionnaire. The sham-PENS treatments failed to produce changes in the degree of pain, physical activity, sleep quality, or daily intake of oral analgesic medications. In contrast, 4-Hz, 15/30-Hz, and 100-Hz stimulation all produced significant decreases in the severity of pain, increases in physical activity, improvements in the quality of sleep, and decreases in oral analgesic requirements (P < 0.01). Of the three frequencies, 15/30 Hz was the most effective in decreasing pain, increasing physical activity, and improving the quality of sleep (P < 0.05). In the global assessment, 40% of the patients reported that 15/30 Hz was the most desirable therapy, and it was also more effective in improving the patients sense of well-being. We conclude that the frequency of electrical stimulation is an important determinant of the analgesic response to PENS therapy. Alternating stimulation at 15-Hz and 30-Hz frequencies was more effective than either 4 Hz or 100 Hz in improving outcome measures in patients with LBP. IMPLICATIONS The frequency of electrical stimulation seems to be an important determinant of the analgesic efficacy of percutaneous electrical nerve stimulation. Mixed low- and high-frequency stimulation was more effective than either low or high frequencies alone in the treatment of patients with low back pain.

Screening for problematic prescription opioid use

The proper medicinal use of opioids, in light of their notorious history and current relation to social ills, continues to be debated and remains unclear in several areas of medicine. This article will review several areas and points of controversy related to screening for potential problematic opioid behavior in chronic nonmalignant pain patients. Controversy over the prescription of opioids for chronic nonmalignant pain continues, despite the growing acceptance of this practice. Indeed, past research supports the beneficial use of opioids for noncancer pain. Unfortunately, traditional definitions of abuse and dependence, with their emphasis on tolerance and withdrawal, are inappropriate for chronic pain patients prescribed opioids. The component of traditional definitions of abuse and dependence that appears most applicable to chronic pain patients centers on the criterion that the patient continue to take the drug (in this case, the opioid) despite negative and harmful effects or despite any decrease in pain level. Although clinical observations exist about risk factors for opioid misuse in chronic pain patients, there is limited research. Further, the area of prescreening for problematic drug behavior is in its infancy. However, researchers have begun to delve into this challenging area and the application of rigorous empirical research will bring us closer to identifying those patients at risk so that their pain is managed without destructive outcomes in other areas of their life.

Percutaneous lumbar sympathectomy: a comparison of radiofrequency denervation versus phenol neurolysis.

A new percutaneous approach to sympathectomy using radiofrequency denervation has seemed to offer longer duration and less incidence of postsympathetic neuralgia as compared to phenol sympathetic blocks. To compare these techniques, 17 patients underwent either phenol lumbar sympathetic blocks (n = 9) or radiofrequency denervation (n = 8). Duration of sympathetic block was followed by a sweat test and temperature measurements. Results indicate that 89% of patients in the phenol group showed signs of sympathetic blockade after 8 weeks, as compared to 12% in the radiofrequency group (P less than 0.05). Although the incidence of post sympathetic neuralgia appears to be less with radiofrequency denervation, further refinement of needle placement to ensure complete lesioning of the sympathetic chain will be required before the technique can offer advantages over current phenol techniques.

An opioid screening instrument: Long-term evaluation of the utility of the pain medication questionnaire

Abstract:  The Pain Medication Questionnaire (PMQ) was designed to assess the risk for opioid medication misuse in chronic pain patients. A preliminary study showed a positive relationship between higher PMQ scores and concurrent measures of substance abuse, psychopathology, and physical/life‐functioning. Using a larger sample size, the present study sought to replicate these findings, and to expand upon them by examining the relationship between PMQ scores and various treatment outcomes. The PMQ was administered to 271 newly evaluated chronic pain patients who were subsequently re‐evaluated immediately post‐treatment, as well as six months following discharge. Subgroups were then formed according to the lowest (L‐PMQ), middle (M‐PMQ), and highest (H‐PMQ) one‐third of PMQ total scores. It was found that the H‐PMQ group was 2.6 times more likely to have a known substance‐abuse problem, 3.2 times more likely to request early refills of prescription medication, and 2.3 times more likely to drop out of treatment, as compared to the L‐PMQ group. They also had diminished biopsychosocial functioning. In addition, at six months following discharge, patients who completed the program experienced a significant decrease in PMQ scores over time relative to those patients who were unsuccessfully discharged from the program or who dropped out. This study represents the second stage in the development of a psychometrically sound screening tool for measuring risk for opioid medication misuse among chronic pain patients, and findings suggest the long‐term utility of the PMQ in identifying patients who are more likely to complete and benefit from a pain management program.

Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care

Chronic pain, a debilitating medical condition affecting approximately 15% of the US population, leads to individual suffering and costs to society in terms of health care dollars and lost productivity. To examine the effectiveness of a comprehensive pain management program, data from 108 program participants were evaluated. Preprogram, postprogram, and 6-month follow-up data were collected from 80 participants, and preprogram, postprogram, and 1-year data were collected from 46 participants. Outcomes data from several domains were assessed: pain severity, emotional distress, interference of pain on function, perceived control of pain, treatment helpfulness, and number of hours resting. Within-subject repeated-measure analyses of variance found statistically significant findings on the six outcome measures utilized in this study for both the 6-month and 1-year samples. Examination of 95% confidence intervals revealed no overlap in pretreatment scores with 6-month and 1-year outcomes in five of the six domains studied. Mean scores on emotional distress did not maintain statistical significance in the 6-month or 1-year review. Overall, this study strengthens the case for interdisciplinary care for chronic pain management and provides evidence for the long-term effectiveness of this therapy. Furthermore, this study lends support to the notion that interdisciplinary treatments are effective in targeting multiple domains affected by the pain condition.

Lumbar radiofrequency sympatholysis

PURPOSE The purpose of this article is to present a modified technique for lumbar radiofrequency sympatholysis and to compare the results with chemical sympatholysis. METHODS Eight patients underwent the percutaneous procedure on an outpatient basis. Sympatholysis was produced with a radiofrequency lesion generator according to distinct anatomic criteria. RESULTS Six of eight patients met previously used criteria for sympatholysis 8 weeks after the procedure. Postsympatholytic neuralgia occurred transiently in 50% of patients. CONCLUSIONS The technique produces sympatholysis comparable to that produced by phenol 6%, while it theoretically avoids the risk of neurologic deficits associated with chemical agents. The technique may be useful in patients for whom surgical sympathectomy is undesirable.

Comparison of epidural Depo-Medrol vs. aqueous betamethasone in patients with low back pain.

Abstract:  Despite the popularity of epidural steroid injections for low back pain, there still remains a lack of consensus on which type of steroid to inject. Most comparison studies regarding epidural steroids are based on an assumption that different types of steroids are equal as long as equipotent doses are utilized.