Quynh Pham

Introduction of a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement noncompliance.

The Prescription Drug Use Questionnaire (PDUQ) is one of several published tools developed to help clinicians better identify the presence of opioid abuse or dependence in patients with chronic pain. This paper introduces a patient version of the PDUQ (PDUQp), a 31-item questionnaire derived from the items of the original tool designed for self-administration, and describes evidence for its validity and reliability in a sample of patients with chronic nonmalignant pain and on opioid therapy. Further, this study examines instances of discontinuation from opioid medication treatment related to violation of the medication agreement in this population, and the relationship of these with problematic opioid misuse behaviors, PDUQ and PDUQp scores. A sample of 135 consecutive patients with chronic nonmalignant pain was recruited from a multidisciplinary Veterans Affairs chronic pain clinic, and prospectively followed over one year of opioid therapy. Using the PDUQ as a criterion measure, moderate to good concurrent and predictive validity data for the PDUQp are presented, as well as item-by-item comparison of the two formats. Reliability data indicate moderate test stability over time. Of those patients whose opioid treatment was discontinued due to medication agreement violation-related discontinuation (MAVRD) (n=38 or 28% of sample), 40% of these (n=11) were due to specific problematic opioid misuse behaviors. Based upon specificity and sensitivity analyses, a suggested cutoff PDUQp score for predicting MAVRD is provided. This study supports the PDUQp as a useful tool for assessing and predicting problematic opioid medication use in a chronic pain patient sample.

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.

MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy.

Fish DE, Kobayashi HW, Chang TL, Pham Q: MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. Objective:To analyze whether magnetic resonance imaging (MRI) findings can be used to predict therapeutic responses to cervical epidural steroid injections (CESI) in patients with cervical radiculopathy. Design:Retrospective single-center study. Patients were categorized by presence or absence of four types of cervical MRI findings (disk herniation, nerve root compromise, neuroforaminal stenosis, and central canal stenosis). Thus, for each of the four types of MRI findings, there was a positive-MRI arm and a negative-MRI arm. Severities of these MRI findings were also noted. The treatment outcome variable was the change in Neck Disability Index (NDI) score after CESI. For each of the four MRI finding types, t test was done to see if there was any significant difference in the outcome between positive-MRI arm and negative-MRI arm. Then, we repeated the same analyses after adjusting the arms to include only those of “major” radiologic severity in the positive-MRI arms. Results:After inclusion and exclusion criteria were applied, 32 patients were included. Only the presence, vs. absence, of central canal stenosis was associated with significantly superior therapeutic response to CESI (mean NDI improvement of 14.14 in positive-MRI arm, vs. mean NDI worsening of 2.11 in negative-MRI arm; P = 0.012). After controlling for other MRI finding types, the statistical significance still held for central canal stenosis (&bgr; = −0.438; P = 0.022). When only the patients with MRI findings of major severities were considered as positive results, central canal stenosis was still the only finding type associated with significantly superior outcome (mean NDI improvement of 23.00 in positive-MRI arm, vs. mean NDI improvement of 0.85 in negative-MRI arm; P = 0.002). Controlling for other MRI finding types, the statistical significance still held for central canal stenosis (&bgr; = −0.534; P = 0.002). Conclusions:Patients with central canal stenosis achieved significantly better functional outcome after CESI than those without. Hence, the MRI finding of central canal stenosis is a potential indication that CESI may be merited.

Poster 130: Epidemiology and Mechanism of Injury in a Major Collegiate Taekwondo Tournament

ent subjects. Results: Subjects with greater levels of baseline disability on average experienced less improvement in ODI over a course of PT. Data also revealed that for every additional unit of baseline ODI, the odds of a subject being adherent decreased by 2% (P .05). For every 30% decrease in ODI or NRS score from baseline to follow-up, a subject was about two times more likely to be adherent to PT (respectively, P .076 and P .001). Conclusions: PT is a suitable treatment for subjects with a wide range of back-specific disability, but may be less appropriate for patients with very severe disability with an ODI 60%, at least until symptoms are better controlled.

Poster 448: Prolotherapy for the Treatment of Interspinous Ligament Injury: A Case Report

Discussion: Ultrasound-guided superficial cervical plexus hydrodissection is an effective and long-lasting way to separate the entrapped nerve from the adhesive scar tissues and alleviate the pain. Instead of lidocaine or corticosteroid, we used pure D5W, which resupplied the glucopenic, neuropathic nerve without the risk of systemic complications. The remaining pain may be related to myofascial imbalance due to trapezius muscle weakness. The axonal damage of the accessory nerve may take some more time to reinnervate in order to possibly correct the shoulder dyskinesis. Conclusions: Ultrasound-guided superficial cervical plexus hydrodissection can effectively and sustainably alleviate the pain from superficial cervical plexus entrapment. Level of Evidence: Level V

Poster 389 Is an Integrative Approach Effective in Managing Chronic, Refractory Pain in Veterans?

Disclosures: Chirag Vora: I Have No Relevant Financial Relationships To Disclose Objective: To test the hypotheses that veterans with refractory pain who participate in an intense outpatient integrative rehabilitation program have improved vitality, perceived pain, and ability to perform ADLs compared to their baseline. Design: The Comprehensive Pain Rehabilitation Program (CPRP) was recently developed at the VA Greater Los Angeles Healthcare System to assist patients in managing chronic pain that was refractory to traditional treatments. CPRP is a 10-week program in which veterans learn to manage their pain from an interdisciplinary team consisting of physicians from various specialties, psychologists, physical therapists, occupational therapists, integrative health and healing providers, and health coaches. Patients are educated on the biopsychosocial theory, pain-distress-disuse cycle, relaxation training, stress management, pacing, behavioral activation, cognitive restructuring, mindfulness, behavioral treatment for insomnia, and flare planning. Additionally, sessions include relaxation training, healing touch, aromatherapy, yoga, comfort massage. Setting: Outpatient chronic pain and rehabilitation clinic. Participants: To date, 58 participants have enrolled and 36 have completed the program. Interventions: An integrative rehabilitation program. Main Outcome Measures: Outcome measures include the pain outcome questionnaires, functional measures, and patient satisfaction ratings. T-test analysis for pre-interventions and post-intervention scores was used. Results: Preliminary results showed statistically significant improvements with perceived ability to perform ADLs (P value: .001), vitality (P value: .042) and overall pain scores (P value: .012). Conclusions: Veteran patients with chronic pain who have completed the integrative CPRP 10-week course demonstrated significant improvements with ADLs, vitality, function, and quality of life. This integrative approach may be a sustainable model to treat veteran patients with chronic pain. Further studies are recommended. Level of Evidence: Level III

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.

Poster 107:Gabapentin’s effect on functional outcome after epidural spinal injections for lumbar radiculopathy.1

Abstract Objective: To determine whether the addition of gabapentin can influence functional outcome in patients undergoing lumbar spinal injections for chronic pain. Design: Retrospective study of functional outcome in patients undergoing lumbar epidural spinal injections (ESIs) with and without the addition of gabapentin. Setting: Clinic. Participants: Subjects with chronic low back and radicular pain in the lower extremity were evaluated for functional improvement after ESI. The addition of gabapentin use was factored into the assessment. Interventions: Fluoroscopic guidance of ESI done at the clinically suspected level in the lumbar region. Main Outcome Measures: Oswestry Disability Index (ODI) and verbal rating scale (VRS) for current pain severity. Results: 75 patients with a radiculopathy were evaluated for an ESI. 29 were on gabapentin and 46 were not. The mean gabapentin use ± SD prior to injections was 1662±950mg. The patients were followed postinjection on average for 10.8±3.9 weeks. Posttreatment ODI score (61.9±16.2) was significantly improved ( P P P Conclusions: Subjects undergoing ESI for chronic radicular pain, who were using gabapentin prior to injection, did not show significant improvement in functional outcome as measured by the ODI or in current pain intensity as measured by the VRS. This study did not demonstrate that gabapentin use prior to spinal procedures has any benefit on the outcome of spinal injections in patients with chronic pain. The limitation of the study was the lack of patients on gabapentin and low functional improvement after ESI. The timing of gabapentin use and the dose of maximal therapeutic benefit were not evaluated by this study.

Abstract 13: Use of electromyography to predict functional outcome after epidural spinal injections for lumbar radiculopathy.1

Abstract Objective: To determine if electromyographic diagnostic evaluation can predict functional outcome in patients undergoing lumbar spinal injections. Design: Retrospective study of functional outcome in patients undergoing lumbar interforaminal epidural spinal injections (ESIs) after electromyographic testing. Setting: Clinic. Participants: 39 subjects with low back pain with radicular symptoms into the lower extremity were evaluated for functional improvement after electromyography and ESI. Interventions: Fluoroscopic guidance of interforaminal ESI in the lumbar region was performed where positive clinical or electromyographic levels were suspected. Main Outcome Measures: Oswestry Disability Index (ODI) and Verbal Rating Scale (VRS) for current pain severity. Results: Electromyography diagnosed 18 patients with a radiculopathy; 21 had a normal or negative examination. Patients were followed postinjection on average for 10.8±3.9 weeks. Pretreatment ODI scores ± SD did not differ significantly between groups showing positive radiculopathy (72.3±12.7) or negative electromyographic findings (65.9±18.6) (P>.05). There was significantly greater improvement of ODI rating for electromyography positive radiculopathy (7.11±9.5) compared with negative electromyography (3.2±17.4) (P .05). The VRS mean improvement did not differ significantly between the positive electromyography group (1.8±1.2) and the negative electromyography group (1.2±1.2) (P>.05). Conclusions: Subjects undergoing interforaminal ESI, who had a positive radiculopathy by electromyography prior to injection, showed significant improvement in functional outcome as measured by the ODI but not as measured by current pain intensity on the VRS. This study showed the importance and diagnostic value of electromyography for radiculopathy evaluation prior to spinal procedures and the difficulty of pain evaluation outcome by using the VRS.