Jessica M. Ketchum

What is the source of chronic low back pain and does age play a role

OBJECTIVE The objective of this study was to estimate the prevalence, mean age, and association of prevalence and age of lumbar internal disc disruption (IDD), facet joint pain (FJP), sacroiliac joint pain (SIJP), spinal and pelvic insufficiency fractures, interspinous ligament injury/Baastrups Disease, and soft tissue irritation by fusion hardware. DESIGN The studys design was a retrospective chart review. SETTING The study was set in an academic spine center. PATIENTS A total of 378 cases from 358 patients were reviewed of which 170 cases from 156 patients who underwent diagnostic procedures were included. INTERVENTIONS Discography, dual diagnostic facet joint blocks, intra-articular sacroiliac joint injections, anesthetic injections of painful interspinous ligaments/opposing spinous processes/posterior fusion hardware, or percutaneous augmentation were performed. OUTCOME MEASURES Prevalence and age were analyzed for each diagnosis group. METHODS Patients with recalcitrant low back pain underwent diagnostic procedures based on their clinical presentation until the pain source was identified. RESULTS The prevalence of internal disc disruption, facet joint pain and sacroiliac joint pain was 42%, 31%, and 18%, respectively. Patients with internal disc disruption were significantly younger than those with facet joint pain or sacroiliac joint pain. Increased age was associated with a decreased probability of internal disc disruption and increased probabilities of facet joint pain and sacroiliac joint pain as the source of low back pain until approximately age 70. CONCLUSION Our data confirm the intervertebral disc as the most common etiology of chronic low back pain in adults. Based on our sample, the younger the patient, the more likely low back pain is discogenic in origin. Facetogenic or sacroiliac joint pain is more likely in older patients.

A preliminary investigation of the brain injury family intervention: Impact on family members

Primary objective: To evaluate the benefits of the Brain Injury Family Intervention (BIFI) for families of persons with acquired brain injury and identify factors related to outcomes. Research design: Pre-test, post-test design with outcomes measured immediately after and 3 months following intervention. Methods and procedures: Family members and survivors participated in five 2-hour sessions over 10 weeks which included discussions of typical effects of brain injury, coping with loss and change, managing stress and intense emotions, effective problem-solving, setting reasonable goals and taking care of ones self. Guided by principles of family systems theory (FST) and cognitive behaviour therapy (CBT), the manualized treatment included educational, skill building and psychological support components. Main outcomes and results: Analysis of data derived from family members indicated a greater number of met needs and perceptions of fewer obstacles to receiving services post-treatment and at 3 months follow-up. Before and after treatment, unmarried caregivers reported more unmet needs. Family members of persons with longer acute care lengths of stay reported more unmet needs and greater perceived obstacles to services. Post-treatment differences in family members’ psychological distress, satisfaction with life and functioning were not identified. Conclusions: The investigation provided evidence that family members benefit from interventions designed to meet their unique needs after brain injury. Uncertainties remain about the benefits of intervention to general family functioning and life satisfaction.

A randomized clinical trial of alternative stress management interventions in persons with HIV infection.

Research in psychoneuroimmunology suggests that immunosuppression associated with perceived stress may contribute to disease progression in persons with HIV infection. While stress management interventions may enhance immune function, few alternative approaches have yet been tested. This randomized clinical trial was conducted to test effects of three 10-week stress management approaches--cognitive-behavioral relaxation training (RLXN), focused tai chi training (TCHI), and spiritual growth groups (SPRT)--in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection. Using repeated measures mixed modeling, the authors found that in comparison to the CTRL group, (a) both the RLXN and TCHI groups used less emotion-focused coping, and (b) all treatment groups had augmented lymphocyte proliferative function. Despite modest effects of the interventions on psychosocial functioning, robust findings of improved immune function have important clinical implications, particularly for persons with immune-mediated illnesses.

A multicentre study on the clinical utility of post-traumatic amnesia duration in predicting global outcome after moderate-severe traumatic brain injury

Background: Past research shows that post-traumatic amnesia (PTA) duration is a particularly robust traumatic brain injury (TBI) outcome predictor, but low specificity limits its clinical utility. Objectives: The current study assessed the relationship between PTA duration and probability thresholds for Glasgow Outcome Scale (GOS) levels. Methods: Data were prospectively collected in this multicentre observational study. The cohort was a consecutive sample of rehabilitation patients enrolled in the National Institute on Disability and Rehabilitation Research funded TBI Model Systems (n = 1332) that had documented finite PTA duration greater than 24 h, and 1-year and 2-year GOS. Results: The cohort had proportionally more Good Recovery (44% vs 39%) and less Severe Disability (19% vs 23%) at year 2 than at year 1. Longer PTA resulted in an incremental decline in probability of Good Recovery and a corresponding increase in probability of Severe Disability. When PTA ended within 4 weeks, Severe Disability was unlikely (<15% chance) at year 1, and Good Recovery was the most likely GOS at year 2. When PTA lasted beyond 8 weeks, Good Recovery was highly unlikely (<10% chance) at year 1, and Severe Disability was equal to or more likely than Moderate Disability at year 2. Conclusions: Two PTA durations, 4 weeks and 8 weeks, emerged as particularly salient GOS probability thresholds that may aid prognostication after TBI.

Predictors of marital stability 2 years following traumatic brain injury

Objective: The purpose of the present study was to determine the predictors of continuous marital stability over 2 years post-injury and examine the moderating effects of ethnicity. Design: Retrospective study. Setting: Longitudinal dataset of the TBI Model Systems National Database. Participants: Nine hundred and seventy-seven individuals with primarily moderate-to-severe TBI (751 Caucasians and 226 minorities) hospitalized between 1989–2005. Main outcomes: Marital stability was defined as ‘stably married’ (married at admission and married at follow-up years 1 and 2) and ‘unstably married’ (being single, divorced or separated at any of the two follow-up years). Results: Across the 2 years post-injury, 85% of study participants who reported being married upon admission for TBI had stable marital status, while 15% indicated being separated or divorced. Younger age, being a male with a TBI, suffering a TBI as a result of a violent injury and having moderate injury severity predicted marital instability. Furthermore, within minorities, increases in disability resulted in a higher likelihood of being stably married. Conclusions: These research findings are clinically relevant and assist marital/couples/family intervention therapists and/or rehabilitation professionals to design programmes early after injury to target these at risk couples. Further research on the modifiable factors contributing to marital instability after TBI and potential moderators is needed.

Multivariable Analyses of the Relationships Between Age, Gender, and Body Mass Index and the Source of Chronic Low Back Pain

OBJECTIVE To examine the combined relationships between age, gender, and body mass index (BMI) and the specific source of chronic low back pain. DESIGN Retrospective chart review. SETTING University spine center. PATIENTS Charts from 378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed. INTERVENTIONS Discography, dual diagnostic facet joint blocks, sacroiliac joint injections, anesthetic interspinous ligaments/opposing spinous processes/posterior fusion hardware injections, percutaneous augmentation. OUTCOME MEASURES Chronic low back pain source was the primary outcome variable. Predictor variables included age at initial presentation, gender, and BMI. RESULTS Age, gender, and BMI were each significantly associated with the source of chronic low back pain, after controlling for the effects of each other. Increases in age were associated with significant decreases in the odds of internal disc disruption (IDD) vs facet joint pain (FJP), sacroiliac joint pain (SIJP), and other sources and decreases in the odds of FJP and SIJP vs other sources. Being female was associated with significant increases in the odds of SIJP vs IDD, FJP, and other sources. Increased BMI was associated with significant increases in the odds of FJP vs SIJP. CONCLUSIONS These findings suggest a significant relationship among gender, age, and BMI and structural causes of chronic low back pain. Lumbar IDD is more prevalent in young males while FJP is more prevalent in females with increased BMI. Female gender and low BMI are associated with SIJP.

Prospective study of 3-year follow-up of low-dose intrathecal opioids in the management of chronic nonmalignant pain.

OBJECTIVE   Long-term follow-up with the use of low-dose opioids in intrathecal (IT) drug delivery system (DDS) for the treatment of intractable, severe chronic nonmalignant pain. DESIGN   This is a prospective, cohort long-term outcome study. Intervention.  The intervention was the implantation of DDS. METHOD AND PATIENTS   A total of 61 consecutive patients (60% females, 40% males) with a mean age of 59.2 years and a mean duration of symptoms prior to implant of 6.2 years were referred for implant of DDS for severe intractable noncancer pain. After adequate patient evaluation, each underwent a trial with IT opioids. Three patients failed the trial and 58 patients were implanted. Follow-up was 36 months, with intervals at 6, 12, 18, 24, and 36 months. The Brief Pain Inventory was used for follow-up assessment criteria at baseline prior to implant as well as throughout the duration of the study. OUTCOME MEASURES   Outcome measures included self-reported pain scores (worst and average), functional improvement, and IT dose, and oral opioid consumption. RESULTS   We observed a statistically significant reduction in both worst and average pain from baseline (8.91 and 7.47 at baseline) throughout the duration of the study (4.02 and 3.41, respectively, at 36 months) (P = 0.012 and P < 0.001, respectively). We also documented a statistically significant improvement in physical and behavioral function. All subjects showed a significant reduction in the oral opioid consumption. The dose of IT opioids remained low and virtually unchanged for 36 months of follow-up: 1.4 morphine equivalent/day at 6 months and 1.48 at 36 months. Oral opioid averaged 128.9 mg of morphine equivalent/patient/day at baseline to 3.8 at 3 month and remained at the same level throughout the study. CONCLUSION   Low-dose IT opioid can provide sustained significant improvement in pain and function for long-term follow-up in chronic noncancer pain.

Factors predicting depression among persons with spinal cord injury 1 to 5 years post injury.

OBJECTIVES Estimate changes in prevalence of Major Depressive Disorder (MDD) 1 to 5 years post spinal cord injury (SCI); Identify demographic, injury, and discharge factors associated with MDD at 1 and 5 years post-injury; Identify modifiers of changes in MDD. DESIGN Retrospective. SETTING Model Spinal Cord Injury System. PARTICIPANTS 2,256 adult participants enrolled in the National Spinal Cord Injury Statistical Center between 1999 and 2004. MAIN OUTCOME MEASURE MDD as determined by the Patient Health Questionnaire-9 (PHQ-9). RESULTS Prevalence of MDD was 11.9% at 1 year and 9.7% at 5 years post SCI. Odds of MDD decreased significantly 1 to 5 years post-injury (odds ratio=1.26, 95% confidence interval=1.02, 1.56). At 1 year post-injury, the odds of MDD was greater for persons 35-55 years old at injury, unemployed, having an indwelling catheter or voiding bladder management at discharge, and higher scores on ASIA motor index. At 5 years post-injury, the odds of MDD were greater for females, persons 35-55 years old at injury, those with a high school education or less, those having an indwelling catheter, voiding, and no bladder management at discharge, and higher scores on ASIA motor index. Sex was the only significant modifier. CONCLUSIONS MDD occurs commonly 1 to 5 years post SCI. Sociodemographic, injury, and discharge factors are associated with the development and changes in depression. Future research should expand upon current findings in order to identify, prevent, and reduce the prevalence of MDD after SCI.

Racial Differences in Employment Outcome After Traumatic Brain Injury at 1, 2, and 5 Years Postinjury

UNLABELLED Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, Jha A. Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury. OBJECTIVES To examine racial differences in competitive employment outcomes at 1, 2, and 5 years after traumatic brain injury (TBI) and to determine whether changes in not competitive employment rates over time differ between blacks and whites with TBI after adjusting for demographic and injury characteristics. DESIGN Retrospective cohort study. SETTING Sixteen TBI Model System Centers. PARTICIPANTS Blacks (n=615) and whites (n=1407) with moderate to severe TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Employment status dichotomized as competitively employed versus not competitively employed. RESULTS After adjusting for demographic and injury characteristics, repeated-measures logistic regression indicated that (1) the odds of not being competitively employed were significantly greater for blacks than whites regardless of the follow-up year (all P<.001); (2) the odds of not being competitively employed declined significantly over time for each race (P< or =.004); and (3) changes over time in the odds of not being competitively employed versus being competitively employed were not different between blacks and whites (P=.070). In addition, age, discharge FIM and Disability Rating Scale, length of stay in acute and rehabilitation, preinjury employment, sex, education, marital status, and cause of injury were significant predictors of employment status postinjury. CONCLUSIONS Short- and long-term employment is not favorable for people with TBI regardless of race; however, blacks fare worse in employment outcomes compared with whites. Rehabilitation professionals should work to improve return to work for all persons with TBI, with special emphasis on addressing specific needs of blacks.

Does the location of low back pain predict its source

To evaluate the predictive utility of the pattern of low back pain (LBP) in detecting the source of LBP as internal disk disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP).