Keith Sequeira

A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury

Study design:Systematic review.Objective:To conduct a systematic review of the effectiveness of interventions used to prevent and treat heterotopic ossification (HO) after spinal cord injury (SCI).Setting:St Josephs Parkwood Hospital, London, Ontario, Canada.Methods:MEDLINE, CINAHL, EMBASE and PsycINFO databases were searched for articles addressing the treatment of HO after SCI. Studies were selected by two reviewers and were only included for analysis if at least 50% of the subjects had an SCI, there were at least three SCI subjects and if the study subjects participated in a treatment or intervention. Study quality was assessed by two independent reviewers using the Downs and Black evaluation tool for all studies, as well as the PEDro assessment scale for randomized control trials only. Levels of evidence were assigned using a modified Sackett scale.Results:A total of 13 studies met the inclusion criteria. The selected articles were divided into prevention or treatment of post-SCI HO. Nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, and pulse low-intensity electrogmagnetic field (PLIMF) therapy were reviewed as prophylactic measures. Bisphosphonates, radiotherapy and excision were reviewed as treatments of post-SCI HO.Conclusions:Pharmacological treatments of HO after SCI had the highest level of research evidence supporting their use. Of these, NSAIDs showed greatest efficacy in the prevention of HO when administered early after an SCI, whereas bisphosphonates were the intervention with strongest supportive evidence once HO had developed. Of the non-pharmacological interventions, PLIMF was supported by the highest level of evidence; however, more research is needed to fully understand its role.

Treatment of whiplash-associated disorders - Part II: Medical and surgical interventions

BACKGROUND Whiplash-associated disorder (WAD) is a term used to describe injury due to an acceleration-deceleration mechanism at the neck. In 1995, the Quebec Task Force published a report that contained evidence-based recommendations regarding the treatment of WAD based on studies completed before 1993 and consensus-based recommendations. OBJECTIVE The objective of the present article--the second installment of a two part review on WAD--is to provide a systematic review of the literature published between January 1993 and July 2003 on medical and surgical interventions for WAD using meta-analytical techniques. METHODS OF THE REVIEW Three medical literature databases were searched for identification of all clinical trials on the treatment of WAD. Randomized controlled trials (RCTs) and epidemiological studies were categorized by treatment modality and analyzed by outcome measures. The methodological quality of the RCTs was assessed. When possible, pooled analyses of the RCTs were completed for meta-analyses of the data. The results of all the studies were compiled and systematically reviewed. RESULTS The studies were categorized as medical or surgical interventions. A total of five RCTs and six non-RCTs were evaluated. The mean methodological quality of the RCTs was 7.3 among studies on medical interventions and 7.5 for studies on surgical intervention. Pooled analyses were completed across all treatment modalities and outcome measures. The outcomes of each study were summarized in tables. CONCLUSIONS While several quality RCTs and epidemiological studies have been published since 1993 on medical and surgical interventions, the cumulative evidence is lacking. Moderate evidence exists in support of radiofrequency neurotomy. Evidence for steroid injections, botulinum treatments, carpal tunnel decompression and cervical discectomy is conflicting or unclear. Future research is required to clarify the utility of radiofrequency neurotomy and pulsed electromagnetic field treatment for WAD.

Treatment of whiplash-associated disorders - part I: noninvasive interventions

BACKGROUND A whiplash-associated disorder (WAD) is an injury due to an acceleration-deceleration mechanism at the neck. WAD represents a very common and costly condition, both economically and socially. In 1995, the Quebec Task Force published a report that contained evidence-based recommendations regarding the treatment of WAD based on studies completed before 1993 and consensus-based recommendations. OBJECTIVE The objective of the present article--the first installment of a two-part series on interventions for WAD--is to provide a systematic review of the literature published between January 1993 and July 2003 on noninvasive interventions for WAD using meta-analytical techniques. METHODS OF THE REVIEW Three medical literature databases were searched for identification of all studies on the treatment of WAD. Randomized controlled trials (RCTs) and epidemiological studies were categorized by treatment modality and analyzed by outcome measure. The methodological quality of the RCTs was assessed. When possible, pooled analyses of the RCTs were completed for meta-analyses of the data. The results of all the studies were compiled and systematically reviewed. RESULTS Studies were categorized as exercise alone, multimodal intervention with exercise, mobilization, strength training, pulsed magnetic field treatment and chiropractic manipulation. A total of eight RCTs and 10 non-RCTs were evaluated. The mean score of methodological quality of the RCTs was five out of 10. Pooled analyses were completed across all treatment modalities and outcome measures. The outcomes of each study were summarized in tables. CONCLUSIONS There exists consistent evidence (published in two RCTs) in support of mobilization as an effective noninvasive intervention for acute WAD. Two RCTs also reported consistent evidence that exercise alone does not improve range of motion in patients with acute WAD. One RCT reported improvements in pain and range of motion in patients with WAD of undefined duration who underwent pulsed electromagnetic field treatment. Conflicting evidence in two RCTs exists regarding the effectiveness of multimodal intervention with exercise. Limited evidence, in the form of three non-RCTs, exists in support of chiropractic manipulation. Future research should be directed toward clarifying the role of exercise and manipulation in the treatment of WAD, and supporting or refuting the benefit of pulsed electromagnetic field treatment. Mobilization is recommended for the treatment of pain and compromised cervical range of motion in the acute WAD patient.

A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 - overview and summary.

Whiplash-associated disorder (WAD) represents a significant public health problem, resulting in a substantial socioeconomic burden throughout the industrialized world, wherever costs are documented. While many treatments have been advocated for patients with WAD, scientific evidence of their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence supporting various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) WAD. The present article, the first in a five-part series, provides an overview of the review methodology as well as a summary and discussion of the reviews main findings. Eighty-three studies met the inclusion criteria, 40 of which were randomized controlled trials. The majority of studies (n=47) evaluated treatments initiated in the chronic stage of the disorder, while 23 evaluated treatments for acute WAD and 13 assessed therapies for subacute WAD. Exercise and mobilization programs for acute and chronic WAD had the strongest supporting evidence, although many questions remain regarding the relative effectiveness of various protocols. At present, there is insufficient evidence to support any treatment for subacute WAD. For patients with chronic WAD who do not respond to conventional treatments, it appears that radiofrequency neurotomy may be the most effective treatment option. The present review found a relatively weak but growing research base on which one could make recommendations for patients at any stage of the WAD continuum. Further research is needed to determine which treatments are most effective at reducing the disabling symptoms associated with WAD.

Pharmacotherapy for depression posttraumatic brain injury: a meta-analysis

Objective:To examine the effectiveness of pharmacotherapy for the treatment of depression following traumatic brain injury (TBI). Design:Systematic review and meta-analysis. Multiple electronic databases were searched to identify relevant studies examining effectiveness of pharmacotherapy for depression post-TBI. Clinical trials evaluating the use of pharmacotherapy in individuals with depression at baseline and using standardized assessments of depression were included. Data abstracted included sample size, antidepressant used, treatment timing/duration, method of assessment, and results pertaining to impact of treatment. Study quality was assessed using a modified Jadad scale. Results:Nine studies met criteria for inclusion. Pooled analyses based on reported means (standard deviations) from repeated assessments of depression showed that, over time, antidepressant treatment was associated with a significant effect in favor of treatment (Hedges g = 1.169; 95% confidence interval, 0.849-1.489; P < .001). Similarly, when limited to placebo-controlled trials, treatment was associated with a significant reduction in symptoms (standardized mean difference = 0.84; 95% confidence interval, 0.314-1.366; P = .002). Conclusion:Pharmacotherapy after TBI may be associated with a reduction in depressive symptomatology. Given limitations within the available literature, further well-powered, placebo-controlled trials should be conducted to confirm the effectiveness of antidepressant therapy in this population.

Psychological Distress in Out-Patients Assessed for Chronic Pain Compared to Those with Rheumatoid Arthritis.

Background. Patients diagnosed with chronic pain (CP) and rheumatoid arthritis (RA) represent two samples with overlapping symptoms, such as experiencing significant pain. Objectives. To compare the level of psychological distress among patients diagnosed CP attending a specialist pain clinic with those attending a specialist RA clinic. Measures. A cross-sectional study was conducted at an academic specialist chronic pain and rheumatology clinic. Participants. 330 participants included a CP group (n = 167) and a RA group (n = 163) completed a booklet of questionnaires regarding demographic characteristics, duration, and severity of their pain. Psychological and personality variables were compared between the CP and RA participants using a Multivariate Analysis of Covariance (MANCOVA). Results. Level of psychological distress based on the subscales of the DASS (depression, anxiety, and stress), PASS (escape avoidance, cognitive anxiety, fear of pain, and physiological anxiety), and PCS (rumination, magnification, and helplessness) was significantly higher in the CP group compared to the RA group. Categorization of individuals based on DASS severity resulted in significant differences in rates of depression and anxiety symptoms between groups, with a greater number of CP participants displaying more severe depressive and anxiety symptoms. Discussion and Conclusions. This study found greater levels of psychological distress among CP individuals referred to an academic pain clinic when compared to RA patients referred to an academic rheumatology clinic.

Impact of Abuse on Adjustment and Chronic Pain Disability: A Structural Equation Model.

Introduction/Aim: Sexual abuse, state and trait psychosocial factors, pain intensity, and pain-related disability have been shown to be correlated among individuals with chronic pain. However, the interacting relationships among these factors are poorly understood. The current study aims to test model which examines the effect of abuse, state and trait psychosocial factors, and pain intensity on pain-related disability among individuals with chronic pain. Methods: In total, 229 participants diagnosed with chronic pain were recruited from a specialist chronic pain hospital in London, Ontario. Participants completed self-report measures related to sexual abuse history, pain intensity, personality (anxiety sensitivity, experiential avoidance, perfectionism), and adjustment (depression, anxiety, disability, maladaptive worrying). A path analysis was used to test the relationship among these variables. Results: The model provided a close fit to the data (&khgr;221=17.02; P=0.71; root-mean-square error of approximation=0.00; normal fit index=0.97; comparative fit index=1.0). The model demonstrates the direct and indirect effects of childhood sexual abuse on state and trait psychosocial factors among individuals with chronic pain. Pain anxiety, maladaptive worrying, and pain intensity were the main determinants of pain-related disability. Discussion/Conclusions: The current model has important implications in understanding the interplay of factors involved in adjustment of individuals with chronic pain. Sexual abuse did not have a direct effect on pain-related disability. However, indirect effects through other psychosocial factors were demonstrated.

Stress in patients diagnosed with rheumatoid arthritis compared to chronic pain.

Purpose/Objective: To examine potential differences in cognitions and traitlike factors that relate to stress among individuals diagnosed with rheumatoid arthritis (RA) compared to those with chronic pain (CP). Research Method/Design: A cross-sectional study was conducted with participants recruited from outpatient rheumatology and CP clinics. Participants completed self-report questionnaires of demographics, disease characteristics, cognitions, and traitlike constructs. Correlates of patient stress were considered using hierarchical multiple regression. Results: Analyses included 445 participants: 226 patients diagnosed with RA and 229 patients diagnosed with CP. In participants with RA, excessive worrying and anxiety sensitivity were independently associated with feeling stressed (p < .001), and 29% of the variance in stress scores was explained after adjusting for age, gender, years of education, and average pain intensity. In participants with CP, fear of relaxation, anxiety sensitivity, and pain catastrophizing were independently associated with feeling stressed (p < .001), and 31% of variance in stress scores was explained after adjusting for age, gender, years of education, and average pain intensity. Comparison of the fit of the model in both groups of patients through use of Fisher’s z test found that the set of variables did similarly well for both patients with RA and those with CP, with no significant difference between R2 values (z = .88, p = .388). Conclusions/Implications: This study establishes cognitions and traitlike factors that are related to reports of stress among patients with RA and CP. These factors should be considered when treating and developing interventions for patients who experience increased feelings of stress.