Martin Grabois

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.

Study Design. Clinical practice guideline. Objective. To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain. Summary of Background Data. Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain. Methods. A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. Results. Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations. Conclusion. Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

Sexuality and sexual adjustment of patients with chronic pain

PURPOSE To describe sexual functioning and its relationship with psychological measures in chronic pain patients. METHOD It is a self report survey with a convenience sample. Seventy consenting chronic pain patients responded to a questionnaire. Mean age was 49.9 years (range 29-74); mean pain duration was 146.7 months (range 6-624). Participants endorsed a wide variety of pain conditions. INSTRUMENTS USED: (1) Derogatis Inventory of Sexual Functioning; (2) Multidimensional Pain Inventory; (3) Center for Epidemiological Studies Depression Scale: (4) Multidimensional Health Locus of Control; (5) Hopkins Symptom Check List; (6) Vanderbilt Pain Management Inventory; (7) Coping Strategies Questionnaire. RESULTS Sixty-six per cent of patients were interested in sex, 50% were satisfied with current sexual partner and 20% considered current sexual life to be adequate. Over 70% fantasized at least once a month. Only 44% experienced normal arousal during intercourse; 33% practiced masturbation and 47% were involved in sexual intercourse or oral sex at least once a month. The majority were dissatisfied with orgasmic activities. No relationship was found between pain severity, duration, frequency and sexual functioning. A relationship was found between disability status, age and several psychological variables and various domains of sexual functioning. CONCLUSIONS; Sexual problems are common in chronic pain patients. Patients who reported symptoms of depression and distress had more sexual problems.

Health Professional's Guide to Rehabilitation of the Patient with Osteoporosis

This guide is a summary reference on the rehabilitation principles that should be applied in the treatment and prevention of osteoporosis. As this guide addresses primarily rehabilitation issues required by osteoporotic fracture or low bone mass, the health professional is directed to the National Osteoporosis Foundation’s companion piece, Physician’s Guide to Prevention and Treatment of Osteoporosis (‘Physician’s Guide’), for other treatment approaches. Rehabilitation and exercise are often viewed as a means to improve function, such as activities of daily living (ADL) for patients. Psychosocial factors also impact strongly on functional ability and the general health of the osteoporotic patient. The information in this guide is based on scientific evidence from basic research, consensus from an expert panel convened by the National Osteoporosis Foundation (NOF), clinical studies, and randomized controlled clinical trials. The small number of randomized trials points to the need for more of them in the future. The majority of the studies on rehabilitation approaches and exercise recommendations related to osteoporosis are based on studies among white perimenopausal women. Clearly, osteoporosis affects men and non-white women as well. It can also affect younger as well as older individuals with certain chronic conditions and medication use. Until we have additional data, recommendations for these other populations should be on an individual basis. The committee believes that the guidelines have universal application in terms of recommending life-long, safe activities and exercises for all people. This guide’s recommendations are not intended as rigid standards of practice, but must be tailored for use by physicians in consultation with their patients. Executive Summary

Chapter 15 - Neuropathic pain

Neuropathic pain is a clinical entity that presents unique diagnostic and therapeutic challenges. This chapter addresses the classification, epidemiology, pathophysiology, diagnosis, and treatment of neuropathic pain syndrome. Neuropathic pain can be distinguished from nociceptive pain based on clinical signs and symptoms. Although neuropathic pain presents a significant burden to individuals and society, a more accurate assessment of resource utilization, costs, and impairments associated with neuropathic pain would facilitate appropriate planning of healthcare policies. The underlying pathophysiology of neuropathic pain is not well defined. Several theories regarding the mechanism of neuropathic pain have been proposed, including central and peripheral nervous system sensitization, deafferentation, neurogenic inflammation, and the wind up theory. Neuropathic pain is a clinical diagnosis and requires a systematic approach to assessment, including a detailed history, physical examination, and appropriate diagnostic testing. The mainstay of treatment for neuropathic pain is pharmacological, including the use of antidepressants, antiepileptics, topical anesthetics, and opioids. Nonpharmacological treatments include psychological approaches, physical therapy, interventional therapy, spinal cord stimulation, and surgical procedures. Neuropathic pain is difficult to treat, but a combination of therapies may be more effective than monotherapy. Clinical practice guidelines provide an evidence-based approach to the treatment of neuropathic pain.

Physical medicine and rehabilitation workforce study: The supply of and demand for physiatrists☆☆☆

OBJECTIVE Analysis, results, and implications of a supply and demand workforce model for physical medicine and rehabilitation. Explicit issues addressed include: (1) the supply implications of maintaining current (1994-1995) output of physiatrists from residency programs; (2) the implications of continued growth in managed care on the demand for the services of physiatrists; (3) likely future supply and demand conditions; and (4) strategies to adapt to future conditions. DESIGN A workforce model of the supply and demand for physiatrists was developed. Parameters of the model are estimated using econometric models and by applying the judgments of a consensus panel. The model evaluated several different scenarios regarding managed care growth, competition from other providers and other factors. RESULTS Based on the analysis, physiatrists will continue to be in excess demand through the year 2000. More aggressive growth in managed care can affect this result. CONCLUSIONS Based on an overall assessment of supply and demand conditions, and under the assumption that the supply of new entrants each year remains in the range of 1994-1995 levels, demand for physiatrists will continue to exceed supply, on average, through the year 2000. Excess supply has, and will, emerge in selected geographic areas. If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.

Integrating cancer rehabilitation into medical care at a cancer hospital

In spite of national health care legislative and model program initiatives, cancer rehabilitation has not kept pace with rehabilitation for patients with other medical problems. This article discusses, from a historical perspective, unsuccessful health care legislation related to cancer and problems in establishing and expanding cancer rehabilitation programs. The attempts to establish a cancer rehabilitation program at the Texas Medical Center and the University of Texas M. D. Anderson Cancer Center are reviewed. Lessons learned over past 40 years and strategies for maintaining the success of a cancer rehabilitation program are discussed. Cancer 2001;92:1055–7.

Current Regulations Related to Opioid Prescribing

It is the responsibility of medical professionals to do all that is possible to safely alleviate pain. Opioids are frequently prescribed for pain but are associated with the potential for misuse, addiction, diversion, and overdose mortality, and thus they are strictly regulated. To adhere to legitimate practice standards, physicians and other health care providers who prescribe opioids for pain, particularly on a long‐term basis, need current information on federal and state laws, treatment guidelines, and regulatory actions aimed at reducing opioid‐related harm. The number of opioid‐prescribing policies is increasing as federal and state governments increase scrutiny to alleviate opioid‐related problems in society. Failure to adequately comply with opioid‐prescribing laws and policies may put a prescriber at risk for legal or regulatory sanctions. Necessary actions include thorough documentation of prescribing decisions and assessment and follow‐up of patient risk for opioid misuse or addiction. Tools to check for patient adherence to the prescribed regimen include prescription monitoring databases and urine drug screening. This article presents an overview of the legal and regulatory framework surrounding controlled substances law. It further discusses recent actions at the federal and state level to prevent opioid‐related harm.

Pain management in rehabilitation

Model of Pain and its Management: Martin Grabois, M.D. The Evaluation of Pain Complicating Primary Disabling Disease: Donna Marie Bloodworth, M.D. Pain-Related Psychosocial and Vocational Issues in Rehabilitation: Gabriel Tan, Ph.D. and Sharon Young, M.A. Pain Syndromes Following Spinal Cord Injury: Gary M. Yarkony, M.D., Michelle S. Gittler, M.D., and David J. Weiss, M.D. Post Stroke Pain: Trilok N. Monga, M.D. and Anthony J. Kerrigan, Ph.D. Pain Management in Traumatic Brain Injury: Cindy B. Ivanhoe, M.D. and Zoraya M. Parrilla, M.D. Pain in Multiple Sclerosis: Michael F. Saffir, M.D. and David S. Rosenblum, M.D. Management of Pain Associated with Peripheral Neuropathy: Jaywant J. Patil, M.D. Pain Associated with Poliomyelitis: Carlos Vallbona, M.D. Pain Management Post Amputation: Alberto Esquenazi, M.D. Arthritis Pain: P. Michelle Muelner, M.D. and Victoria A. Brander, M.D. Pain Management and Cancer: Helene Henson, M.D. and Uma Monga, M.D. Burn Pain - Evaluation and Management: Karen J. Kowalski, M.D. HIV Pain Management: Richard T. Jermyn, D.O., Deanna M. Janora, M.D., and Barbara S. Douglas, M.D.

Coital Positions and Sexual Functioning in Patients with Chronic Pain

The objectives of this study were to describe (1) coital positions adopted by chronic back pain patients, (2) and to describe sexual function as assessed by Derogatis Inventory of Sexual Functioning (DISF). In addition, patients were asked questions regarding effects of sexual intercourse on severity of pain, influence of pain over sexual functioning, and perceived factors causing sexual problems. This is a subset (45 patients) of a larger study (70 patients) describing sexual functioning. These 45 patients responded to additional questions as described above. Mean age of the patients was 55.7 years (range 36–74 years). There were 40 male patients. Twenty-five patients (56%) were married. Mean duration of pain was 145.2 months. Thirty-two patients (27 male and 5 female) were sexually active. Eighty-one percent of male and 100% of female patients, who were sexually active, preferred “male superior” position. Of those sexually active, 41% performed sexual intercourse while sitting on a chair. A majority of patients were experiencing problems in all domains of sexual functioning except for fantasy. Thirty-nine patients (87%) reported that pain extremely interfered in performing sexual intercourse. Twenty-nine patients (64%) reported worsening of pain due to sexual intercourse. Majority (n = 34) of the patients (76%) had fear of failure to perform and 25 patients (56%) reported fear of aggravating pain due to sexual activity. There is need for further research in this area.

The American Congress of Rehabilitation Medicine: where do we go from here?

This presidential address reflects on my last 2 years as president of American Congress of Rehabilitation Medicine (ACRM). It recognizes those individuals who have been of significant help and support. The address discusses choices I have made in my professional life including selecting physical medicine and rehabilitation as a subspecialty; committing to an academic career; and choosing to get involved in local, state, national, and international physical medicine and rehabilitation societies. I review my presidential speech of 2001 when I spoke about the path we choose-to succeed or not to succeed. ACRM has come a long way in trying to succeed but continued opportunities remain in obtaining financial security, increased membership, and cost-effective and efficient management. This address includes 11 suggestions designed not only to keep the organization viable but also to allow ACRM to succeed. These suggestions include a new commitment to our strategic plan and the implementation of prioritized goals, reorganization of ACRMs national office, and adherence to a realistic budget. Finally, we must continue to move the agenda of research in rehabilitation forward much more aggressively.