Dixie R. Aragaki

A Randomized Trial of 2 Prescription Strategies for Opioid Treatment of Chronic Nonmalignant Pain

UNLABELLED The use of opioid medications for treating chronic noncancer pain is growing; however, there is a lack of good evidence regarding their long-term effectiveness, association with substance abuse, and proper prescribing guidelines. The current study directly compares for the first time in a randomized trial the effectiveness of a conservative, hold the line (Stable Dose) prescribing strategy for opioid medications with a more liberal dose escalation (Escalating Dose) approach. This 2-arm, parallel, randomized pragmatic clinical trial followed 135 patients referred to a specialty pain clinic at a Veterans Affairs Hospital for 12 months (94% male and 74% with musculoskeletal pain). Primary outcomes included monthly or quarterly evaluations of pain severity, pain relief from medications, pain-related functional disability, and opioid misuse behaviors. All subjects received identical pain treatment except for the application of treatment group specific strategies for opioid prescriptions. No group differences were found for primary outcomes of usual pain or functional disability although the Escalating Dose group did show a small but significantly larger increase in self-rated pain relief from medications. About 27% of patients were discharged over the course of the study due to opioid misuse/noncompliance, but there were no group differences in rate of opioid misuse. PERSPECTIVE The results of this study demonstrate that even in carefully selected patients there is a significant risk of problematic opioid misuse. Although in general there were no statistically significant differences in the primary outcomes between groups, the escalating dose strategy did lead to small improvements in self-reported acute relief from medications without an increase in opioid misuse, compared to the stable dose strategy.

Nonsurgical Treatment for Rotator Cuff Injury in the Elderly

Shoulder pain is a common musculoskeletal complaint in the general population. The elderly population is often afflicted, and rotator cuff problems are among the most common causes of shoulder pain seen in primary care practices. The prevalence of shoulder pain in the elderly has been estimated to range from 21% to 27%, and the prevalence of rotator cuff tear increases with advanced age. The etiology of rotator cuff disease is likely multifactorial, including both extrinsic and intrinsic factors. Rotator cuff dysfunction encompasses a spectrum of pathological changes, ranging from impingement syndrome to rotator cuff tendonitis to rotator cuff tendon tear. In the elderly population, the clinical manifestations from rotator cuff dysfunction can translate into significant morbidity and disabilities, interfering with ability for self care and functional independence. The goals of managing rotator cuff disease are to regain normal shoulder function and biomechanics, and to improve functional abilities in elderly patients. Treatment can consist of various conservative therapies (including ice, simple exercises, medications), and progress to more intensive physical therapy and/or corticosteroid injections. Rotator cuff dysfunction is a common musculoskeletal disorder in elderly patients and is often underdiagnosed and undertreated. Physicians should be aware of the prevalence of rotator cuff disease in this population and provide early diagnosis and treatment to help preserve the functional ability and independence of older patients.

A test of how well the repeatability of courtship predicts its heritability

We compared repeatability and heritability estimates for courtship traits in the housefly Musca domestica L., to test the expectation that the repeatability of a behaviour is an upper-bound estimate of its heritability. The repeatabilities across and within mating partners for two courtship traits, male wing buzzing (Buzz) and female wing extension (Wing-out), were compared to heritabilities calculated from the divergence among subpopulations due to founder-flush events or artificial selection. The males Buzz showed highly significant repeatabilities within and across female partners, but the values ranged widely (0.3-0.5). The intensity of Buzz decreased significantly with successive courtship attempts to the same female, apparently as a male strategy to optimize his efforts to gain copulation by modulating behaviour for specific females. Repeatabilities for female Wing-out within and across male partners were not significant, but this trait yielded significant heritabilities in two assessments (based on successful courtships). We attribute this contradiction to biased sampling because only the subset of reluctant females met the necessary restriction to refuse copulation throughout four successive courtships. These results demonstrate that repeatabilities are labile within individuals and may actually underestimate heritabilities when there is a genetic predisposition not to repeat performance. We concur with related studies that repeatabilities can identify evolutionary potential, but we advise caution in interpreting low values or comparing their absolute values.Copyright 1998 The Association for the Study of Animal Behaviour. Copyright 1998 The Association for the Study of Animal Behaviour.

Immediate Effects of Contralateral and Ipsilateral Cane Use On Normal Adult Gait

To determine the effects of ipsilateral and contralateral cane use on gait kinematics and peak vertical force in young healthy adults.

Behavioral Interventions for Antipsychotic Medication–Associated Obesity: A Randomized, Controlled Clinical Trial

OBJECTIVE To demonstrate the effectiveness of a Diabetes Prevention Program-inspired 12-month behavioral intervention for patients with severe mental illness (SMI) and medication-associated obesity. METHOD This randomized, controlled, parallel, superiority study screened 225 volunteers from November 2005 to August 2008 at the VA Greater Los Angeles Healthcare System. 122 outpatients with DSM-IV-diagnosed SMI taking antipsychotic medications who had ≥ 7% weight gain or body mass index (BMI) > 25 were randomized by computer-generated number to Lifestyle Balance treatment intervention (n = 60) or usual care control (n = 62) groups. Clinical raters were masked to randomization. Treatment intervention included weekly classes and individual counseling for 8 weeks, food and exercise diaries, rewards, caregiver consultations, and monthly booster classes and counseling for 1 year. Controls received self-help materials and visited at equivalent intervals without formal classes or counseling. Outcomes were changes in anthropometric measurements, psychiatric symptoms, health knowledge, and glucose, hemoglobin A1c, and lipid levels. RESULTS Our intention-to-treat analysis found significant differences in predicted trajectory of mean weight change between the groups over 12 months (P < .01), with treatment participants expected to lose an average 4.6 kg, while control participants would gain an average 0.6 kg. BMI and body fat percentage followed the same pattern. Both groups demonstrated statistically significant improvements in health knowledge quiz scores over time (P = .006), without significant difference between groups. CONCLUSIONS Treatment was more effective than usual care control in treating medication-associated obesity, independent of SMI diagnosis, antipsychotic medication, and knowledge gained, suggesting that behavioral interventions are effective in SMI patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00344500.

Poster 253 Efficacy and Safety of a Lifestyle Balance Program for Antipsychotic Medication Associated Obesity

block after being evaluated by 2 independent pain physicians. The patient experienced an excellent result immediately on the procedure table. We will discuss 3 other case scenarios. We will review the medical literature to identify the pain generators after a spinal wedge fracture and evaluate the validity of the entire medical literature about vertebroplasty as a tool for pain management. Discussion: We believe that there has never been mention in the medical literature of thoracic medial branch block compared with the thoracic vertebroplasty for pain management. However, we will provide information about the pain generators in the spinal wedge fracture, and we will explain why we believe that possibly medial branch block would play a tremendous role for pain management in this group of patients.

Poster 317 Dose-Related Response to Ultrasound-Guided Ulnar In-Plane Median Nerve Steroid Injections for Carpal Tunnel Syndrome: A Case Report

Setting: Academic Medical Center and Physical Medicine & Rehabilitation Clinic. Results: After discharge, she struggled to progress and eventually declined in function several months later. She returned to clinic for her 6-month follow-up, and MRI of the cervical spine was ordered. No abnormality on imaging explained her decline, and she was instructed to go to the emergency department for further neurologic work-up. On examination, she exhibited new dysarthria, much weaker strength, diffuse muscular atrophy, and fasciculations. An electrodiagnostic study demonstrated findings of definite amyotrophic lateral sclerosis (ALS) according to the El Escorial criteria with upper and lower motor neuron findings in 4 of 4 areas (bulbar, cervical, thoracic, and lumbosacral). Discussion: The patient’s deficits were initially attributed to lumbar radiculopathy and cervical spinal stenosis. Her decline in function several months later along with speech dysfunction prompted additional testing with an electrodiagnostic study revealing a diagnosis of definite ALS. Conclusions: Early ALS may be confused with other diagnoses such as cervical myelopathy. Careful correlation of electrodiagnostic data with clinical findings is necessary to prevent mis-diagnosis of ALS, prevent potentially harmful procedures, and initiate timely interventions. Level of Evidence: Level V

Poster 109: An Innovative Comprehensive Musculoskeletal Medicine Curriculum for First Year Medical Students

paraspinal and extremity muscle hypertonicity, which caused him to stand with a hyperextended posture and use a gait with a wide base of support. The examination identified increased tone in his paraspinal muscles, maintaining increased cervical spine extension, having proximal right upper extremity strength at 2/5 distally normal, decreased deep tendon reflexes compared to left upper extremity, intact sensation, and positive Hoffman’s sign bilaterally. Magnetic resonance imaging revealed a large posterior osteophyte formation within the disk material from C3-C6 causing marked canal stenosis. Abnormal cord signals indicating a chronic cord compression as well as degenerative bone marrow were detected at those levels. Setting: Tertiary care hospital. Results: The patient’s motor deficit and pain were attributed to an acute chronic cord compression due to canal stenosis caused by degenerative changes to the cervical spine. These changes are attributed to the cervical extension caused by an increased tone in paraspinal muscles in an otherwise well-functioning adult CP patient. The patient was treated conservatively with steroids, a rehabilitation program was instituted, and he started regaining some strength and function. Ultimately, plans were made for a surgical decompression once the acute stage resolved. Discussion: This challenging CP complication adversely affects patients who chronically maintain a high paraspinal extensor muscle tone. Conclusions: Rehabilitation physicians caring for these patients should understand the possible consequences of chronically altered spine biomechanics resulting in degenerative changes.