Elaine S. Date

The rates of false-positive lumbar discography in select patients without low back symptoms.

STUDY DESIGN Experimental disc injections in subjects with no history of low back symptoms. OBJECTIVE To determine in an experimental setting the relative pain response and pain-related behavior in selected subjects without a history of low back pain undergoing lumbar discography. This study aimed to select a study population that more closely represented patients undergoing discography in clinical practice. SUMMARY OF BACKGROUND DATA Previous work has shown that in young, healthy men with little degenerative disc disease and no history of low back problems, discographic injections usually did not cause significant pain. This group differed from the patients who usually undergo discographic evaluation in clinical practice. Most clinical patients are older, have significant degenerative disc disease, have behavioral changes associated with chronic pain, and often have confounding psychosocial troubles. The authors undertook to study discography in subjects without low back pain but with clinical profiles similar to patients undergoing discography in clinical practice. METHODS Twenty-six individuals, mean age 43 years, with no history of low back pain had lumber discography according to the strict protocol of Walsh et al. Of these, 10 were pain-free; 10 had chronic neck and arm pain, but no low back symptoms; and 6 had primary somatization disorders without low back symptoms.- RESULTS Significant positive pain response and pain-related behavior with discography were found in 10% of the pain-free group, in 40% of the chronic cervical pain group, and in 83% of the somatization disorder group completing the injections. Twenty-four subjects had negative control discs. Discs with annular disruption were more likely to be painful on injection, particularly in those individuals with ongoing compensation issues, chronic pain, or abnormal psychological testing.- CONCLUSION If strict criteria are applied, the rate of false-positive discography may be low in subjects with normal psychometric profiles and without chronic pain. Significantly painful injections were very common in subjects with annular disruption and chronic pain or abnormal psychometric testing.

Ultrasound guidance in caudal epidural needle placement.

Background:This study was conducted to investigate the feasibility of using ultrasound as an image tool to locate the sacral hiatus accurately for caudal epidural injections. Methods:Between August 2002 and July 2003, 70 patients (39 male and 31 female patients) with low back pain and sciatica were studied. Soft tissue ultrasonography was performed to locate the sacral hiatus. A 21-gauge caudal epidural needle was inserted and guided by ultrasound to the sacral hiatus and into the caudal epidural space. Proper needle placement was confirmed by fluoroscopy. Results:In all the recruited patients, the sacral hiatus was located accurately by ultrasound, and the caudal epidural needle was guided successfully to the sacral hiatus and into the caudal epidural space. There was 100% accuracy in caudal epidural needle placement into the caudal epidural space under ultrasound guidance as confirmed by contrast dye fluoroscopy. Conclusions:Ultrasound is radiation free, is easy to use, and can provide real-time images in guiding the caudal epidural needle into the caudal epidural space. Ultrasound may therefore be used as an adjuvant tool in caudal needle placement.

Size and Aggregation of Corticosteroids Used for Epidural Injections

OBJECTIVE The purpose of this study was to document particulate size in commonly used corticosteroid preparations. Inadvertent injection of particulate corticosteroids into a vertebral or foraminal artery can cause brain and spinal cord embolic infarcts and the size of the particles could be directly related to the chance that a clinically significant infarct would occur. One might assume that corticosteroids with particles significantly smaller than red blood cells might be safer. DESIGN The following four types of corticosteroid preparations were used in various solutions and evaluated under light microscopy: dexamethasone sodium phosphate injection, triamcinolone acetonide injectable suspension, betamethasone sodium phosphate and betamethasone acetate injectable suspension, and methylprednisolone acetate injectable suspension. RESULTS Dexamethasone sodium phosphate particle size was approximately 10 times smaller than red blood cells and the particles did not appear to aggregate; even mixed with 1% lidocaine HCl solution and with contrast dye, the size of the particles were unchanged. Triamcinolone acetonide and betamethasone sodium phosphate showed variable sizes; some particles were larger than red blood cells, and aggregation of particles was evident. Methylprednisolone acetate showed uniformity in size and the majority were smaller than red blood cells which were not aggregated, but the particles were densely packed. CONCLUSIONS Compared with the particulate steroid solutions, dexamethasone sodium phosphate had particles that were significantly smaller than red blood cells, had the least tendency to aggregation, and had the lowest density. These characteristics should significantly reduce the risk of embolic infarcts or prevent them from occurring after intra-arterial injection. Until shown otherwise in clinical studies, interventionalists might consider using dexamethasone or another corticosteroid preparation with similar high solubility and negligible particle size when performing epidural injections.

Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

OBJECTIVES To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. DESIGN Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. SETTING Four Veterans Administration acute inpatient TBI rehabilitation programs. PARTICIPANTS Adult veterans or active duty military service members (N=360) with moderate to severe TBI. INTERVENTIONS One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. MAIN OUTCOME MEASURES The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. RESULTS The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. CONCLUSIONS Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

The prevalence of lumbar paraspinal spontaneous activity in asymptomatic subjects

Electrodiagnostic findings of fibrillations and positive sharp waves in the lumbosacral paraspinals in patients without previous back surgery has been generally considered to be abnormal, consistent with posterior rami denervation. In some cases, it is the only abnormality on the electromyographic examination. This study was undertaken to determine the prevalence of abnormal spontaneous activity in lumbosacral paraspinals in asymptomatic individuals. Nine (14.5%) of 62 subjects studied had positive sharp waves or fibrillations noted on the needle examination of bilateral lumbosacral paraspinal muscles. There was a significant increase in the prevalence of abnormal activity with increasing age. This suggests that caution should be taken in attributing radiculopathy as the etiology of low back pain when electromyographic lumbosacral paraspinal abnormalities are the only positive findings in the middle‐aged or older individual.

Therapeutic Use of Botulinum Toxin Type A in Treating Neck and Upper-Back Pain of Myofascial Origin: A Pilot Study

OBJECTIVE To determine the efficacy of botulinum toxin type A (BTX-A) in treating neck and upper-back pain of myofascial origin. DESIGN A randomized, double-blind, placebo-controlled pilot study. SETTING Outpatient physical medicine and rehabilitation clinic of a university-affiliated tertiary hospital. PARTICIPANTS A total of 29 subjects enrolled from among 45 screened patients. No subject withdrawal due to serious adverse events occurred. INTERVENTION Subjects were evaluated at baseline, received a 1-time injection of either BTX-A (treatment group) or saline (control group), and were followed up at 2 weeks and at months 1, 2, 3, 4, and 6. MAIN OUTCOME MEASURES Visual analog scale (VAS) for pain, the Neck Disability Index (NDI), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36). RESULTS Improvements in the VAS and NDI scores were seen in the treatment group but were not significant when compared with the controls. Statistically significant improvements for the treatment group were seen in the SF-36 bodily pain (at months 2 and 4) and mental health (at month 1) scales but not in the other scales, nor in the summary measures. No serious adverse events were reported. CONCLUSIONS Trends toward improvements in VAS and NDI scores of the BTX-A group are encouraging, but they were possibly due to a placebo effect and were not statistically significant. The BTX-A subjects, at certain time points, showed statistically significant improvements in the bodily pain and mental health scales of the SF-36 compared with controls. Our study had limited power and population base, but the results could be used to properly power follow-up studies to further investigate this topic.

Electrophysiologic abnormalities of auditory and visual information processing in patients with traumatic brain injury.

Lew HL, Lee EH, Pan SSL, Date ES: Electrophysiologic abnormalities of auditory and visual information processing in patients with traumatic brain injury. Am J Phys Med Rehabil 2004;83:428–433. Objective:Through both auditory and visual modalities, we sought to explore the efficacy of event-related potentials in detecting residual cognitive impairments in patients with traumatic brain injury (TBI). Design:Control subjects and TBI patients with favorable recovery were recruited. Pure tone and primary color discrimination tasks were utilized to elicit auditory and visual event-related potentials, respectively. All subjects were instructed to push a response button when they detected the target stimuli. Both behavioral and electrophysiologic responses were obtained simultaneously. We analyzed the event-related potential waveforms and examined the differences in amplitude, latency, behavioral reaction time, and response accuracy. Results:A total of 11 TBI patients and 11 control subjects were tested. Results showed that (1) TBI patients had significantly lower P300 amplitude in both auditory (11.2 vs. 22. 7 μ V) and visual (11.6 vs. 20.9 μ V) domains, (2) TBI patients had significantly longer P300 latency in both auditory (355 vs. 294 msecs) and visual (376 vs. 341 msecs) modalities, and (3) although there was no significant difference in response accuracy (97.7%vs. 100%), reaction time for both auditory and visual tasks were significantly longer in TBI patients (auditory, 404 vs. 277 msecs; visual, 397 vs. 346 msecs). Conclusion:Although TBI patients with good recovery showed similar response accuracy when compared with control subjects, they demonstrated significantly poorer performance in both electrophysiologic and behavioral responses. Diminished amplitudes and prolonged latencies in P300 responses indicate impaired organization and categorization of incoming sensory information; prolonged behavioral reaction times suggest slowing in the response execution process. Clinical and theoretical implications and goals for continued research are discussed.

The Natural Resolution of a Lumbar Spontaneous Epidural Hematoma and Associated Radiculopathy

This is a report of a 37-year-old man who, while lifting a heavy box, developed severe low-back pain radiating into the right anterior thigh. The only clinical signs were paraspinal muscle spasm and a positive femoral nerve stretch test on the right. An electromyographic study demonstrated denervation in the right L2, L3, and L4 myotomes and paraspinal muscles. Magnetic resonance imaging (MRI) showed a large L1-2 anterior epidural hematoma compressing the spinal cord. The patients pain gradually improved with conservative management and he returned to light work after 4 weeks. Repeat electromyographic and MRI studies were normal, indicating a resolution of the radiculopathy and hematoma. The diagnosis and management of spontaneous epidural hematomas are discussed.

Mentorship in physical medicine and rehabilitation residencies.

Mentorship is considered by many authorities as being possibly the most important developmental tool for the progression of a professional in training. In recent years, progressively increasing support of mentoring programs has been documented, especially in business, academia, and overall career development. Despite its recognized importance, there is a paucity of literature examining the needs of physicians in residency training programs in regard to mentorship. A 21-item questionnaire was sent to all physical medicine and rehabilitation (PM&R) residents in training in United States residency programs in May of 1993. The objectives of this survey were 3-fold: to assess interest in mentorship among PM&R residents, to determine the effect of preresidency mentorship on candidates choosing PM&R as a specialty, and to identify the factors that establish a successful mentorship in PM&R residency. A response rate of 36.2% (406/1123) was obtained. Analysis of the results indicated that 97.3% (390/401) of the respondents were interested in mentorship programs during PM&R residency; however, only 28.1% (114/406) had a mentor at the time of the survey. Before residency, 35.4% (143/404) of the respondents had a mentor, and of those, 75.9% (107/141) indicated that mentorship had a positive effect on their decision to choose PM&R as a specialty. Regarding the current mentorship, respondents benefited the most in the categories of increased knowledge of PM&R, 72.8% (83/114), and improved clinical skills, 65.8% (75/114). The least satisfaction was with the mentors assistance with a research project, 46% (52/113), and with the effect of mentorship on the residents visibility and reputation, 38.6% (44/114). Overall resident satisfaction with mentorship was significantly higher (P < 0.0001) in mentorships formed by free choice compared with those that were formally assigned by the residency program. Success of mentorship significantly correlated (P < 0.0001) with frequency of communication between mentor and protégé, while gender and ethnicity had no effect.

Practical and theoretical considerations in designing rehabilitation trials: the DVBIC cognitive-didactic versus functional-experiential treatment study experience.

This is a descriptive article outlining issues in the development and implementation of a multisite randomized rehabilitation trial for brain injury treatment. The goal of this article is to present practical and theoretical considerations in designing and conducting multicenter rehabilitation trials. Practical issues discussed include (a) treatment setting, (b) patient accessibility in determining the research question of interest, as well as inclusion and exclusion criteria, (c) research protocol development in the context of rehabilitation standard of care, and (d) protocol treatments in the context of realistic cost-benefits analysis. Rehabilitation theory is discussed as playing an important role designing the specifics of the protocol interventions. The Defense and Veterans Brain Injury Center Veterans Health Administration cognitive-didactic versus functional-experiential study methodology is used for illustrative purposes. This study evaluated 2 alternative approaches to treatment: one focusing on underlying cognitive processes and the second on errorless learning in everyday functional situations. Lessons learned over the course of completing the treatment trial are discussed.