Samuel M. Bierner

A Cost Utility Analysis of Interdisciplinary Early Intervention Versus Treatment as Usual For High-Risk Acute Low Back Pain Patients

Chronic pain is a costly and debilitating condition that has proven difficult to treat, solely with medical interventions, due to the complex interplay of biological, psychological, and social factors in its onset and persistence. Many studies have demonstrated the effectiveness of interdisciplinary treatment that includes psychosocial interventions for low back pain. Nevertheless, these interventions continue to be under‐utilized due to concerns of cost and applicability. The present study utilized a cost utility analysis to evaluate effectiveness and associated costs of interdisciplinary early intervention for individuals with acute low back pain that was identified as high‐risk for becoming chronic. Treatment effectiveness was evaluated using a standard pain measure and quality‐adjusted life years, and associated medical and employment costs were gathered for 1 year. Results indicated that subjects improved significantly from pretreatment to 1‐year follow‐up, and that the early intervention group reported fewer health‐care visits and missed workdays than the treatment as usual group. The majority of 1,000 bootstrapped samples demonstrated the dominance of the early intervention program as being both more effective and less costly from a societal perspective. The early intervention treatment was the preferred option in over 85% of samples within an established range of acceptable costs. These results are encouraging evidence for the cost‐effectiveness of interdisciplinary intervention and the benefits of targeted early treatment.

Needle electromyography predicts outcome after lumbar epidural steroid injection

Introduction: Needle electromyography (NEE) would be more valuable if it could predict outcomes after lumbar epidural steroid injections (LESIs) in lumbosacral radiculopathy (LSR). Methods: We investigated the predictive value of NEE for outcome after LESI compared with other known predictive variables in 89 subjects with clinical LSR. Seventy patients completed the study, which included diagnostic lower extremity NEE and LESI. Outcome measures included changes in pain, physical function, and psychosocial function [assessed using the Pain Disability Questionnaire (PDQ)]. Results: NEE was an independent predictor of long‐term pain improvement after LESI and was not predictive of PDQ functional improvement. A regression model, with NEE as one of several independent variables, showed strong outcome‐predictive ability. Conclusions: NEE is an independent predictor of long‐term pain relief after LESI for LSR. Abnormal NEE is predictive of better outcome than normal NEE. A regression equation including NEE and other independent predictors was predictive of pain and functional outcomes. Muscle Nerve, 2012

Comparison of glucose metabolism and cerebral blood flow during cortical motor activation.

Regions of cerebral cortex activated in normal subjects making simple, repetitive, voluntary wrist movements were studied with positron emission tomography (PET). The regional cerebral metabolic rate of glucose utilization was studied with 2‐[18F]fluoro‐2‐deoxy‐D‐glucose (FDG), and regional cerebral blood flow was studied with 15O‐labeled water. No significant activation was found with the cerebral metabolic rate studies. Studies of regional cerebral blood flow showed significant activation of the contralateral sensorimotor cortex region of 42%, of the ipsilateral sensorimotor cortex region of 19%, and of the medial frontal cortex of 30% compared with the resting state. Increases in blood flow in the contralateral sensorimotor cortex and medial frontal cortex were visible on every activated scan. Measurement of regional cerebral blood flow seems to be more sensitive than regional cerebral metabolic rate of glucose utilization for studying cortical activation with voluntary movement.

Role of electrodiagnosis in patients being considered for epidural steroid injections

Electrodiagnostic (EDX) evaluation, and, more specifically, electromyography (EMG), has a well‐established role in the diagnostic confirmation of cervical and lumbar radiculopathy. The role of EMG in prognostication, however, is less established and remains a topic of debate. The purpose of this article is to evaluate the diagnostic and prognosticating role of EMG in cervical and lumbar radiculopathies, and to assess the utility of EMG in predicting outcomes after epidural steroid injections (ESI). A review of the existing literature strongly supports a prognosticating role for EDX in predicting outcomes after lumbar ESI in lumbosacral radiculopathies (LSR). Although limited research regarding outcome prediction after cervical ESI in cervical radiculopathies has been performed, no study has specifically evaluated the utility of EMG in predicting outcomes for cervical ESI, and this topic requires further investigation. An EDX evaluation can provide clinicians with accurate and reliable diagnostic information (level I or level II evidence) in the evaluation of patients with lumbosacral radiculopathies, and can provide more valid prognostic information (level I evidence) regarding potential benefits of lumbar ESI. An EDX evaluation, therefore, can enhance a clinicians ability to advise patients on the most appropriate and efficacious evaluation and management plan for the treatment of painful radiculopathies.

Does Lumbar Dorsal Ramus Syndrome Have an Objective Clinical Basis

Degenerative processes can cause chronic low back pain that occasionally creates impingement of the lumbar dorsal rami, resulting in a clinical syndrome previously described as lumbar dorsal ramus syndrome (LDRS).

Do Electrodiagnostic Variables Correlate with Functional Outcomes in CarpalTunnel Syndrome

Background: The most common entrapment neuropathy seen in electrodiagnostic (EDX) laboratories is carpal tunnel syndrome (CTS). The diagnostic value of EDX with regard to CTS is well-established, but EDX’s predictive value is unclear. To date, only one study has attempted to establish a relationship between EDX findings and a patient’s clinical status pre- and post-treatment, and there was no significant relationship found. Objective: To establish a relationship between EDX variables and clinical severity assessment with Disabilities of the Arm, Shoulder, and Hand (DASH) scores at a single point in time and over a period of time. Methods: The study was a prospective single group cohort. 41 patients referred to an EDX clinic with suspected diagnoses of CTS were enrolled. Patients underwent EDX studies and completed DASH questionnaires at initial and follow-up visits at 8-month to 12-month intervals. Data collected included median sensory, mixed, and motor latencies, amplitudes, conduction velocities, and needle electromyography (EMG). Correlation coefficients were determined between EDX data variables and severity assessment (independent variables) and patients’ DASH questionnaire measures (dependent variables) at initial and follow-up assessments. Results: Change in DASH score over time positively correlated with left distal median motor latency (DMML) decrement and right transcarpal median sensory conduction block and negatively correlated with left median sensory nerve action potential (SNAP) amplitude decrement percentage, right needle EMG motor unit morphology abnormality, and right median forearm motor conduction velocity increment. The correlations observed are of unclear significance since the DASH scores themselves did not change significantly over time. Conclusions: Objective EDX data coupled with patient-reported outcome (PRO) measures such as the DASH score may be more meaningful in directing clinical care than either of them alone.

Intraarticular Triamcinolone versus Hyaluronate Injections for Low Back Pain with Symptoms Suggestive of Lumbar Zygapophyseal Joint Arthropathy: A Pragmatic, Double Blind Randomized Controlled Trial

Objective The aim of the study was to compare hyaluronate with triamcinolone injections in treating chronic low back pain suggestive of lumbar zygopophyseal joint arthropathy. Design This was a prospective, double-blind, randomized controlled trial. Thirty subjects were randomly assigned to receive bilateral L3-S1 lumbar zygopophyseal joint injections with triamcinolone (KA) or Synvisc-One (HA). Pain (visual analog scale) and Pain Disability Questionnaire scores at 1, 3, and 6 mos were evaluated. Results No significant intergroup differences (P > 0.05) in outcomes were noted in the 30 recruited subjects. For KA/HA (baseline; 1 mo; 3 mos; 6 mos), visual analog scale scores were the following: 70 (15)/74 (10); 58 (29)/45 (25); 58 (29)/56 (25); and 59 (28)/63 (24), respectively. Pain Disability Questionnaire scores were the following: 100 (23)/102 (28); 77 (30)/74 (34); 87 (26)/74 (36); and 96 (25)/79 (25). Overall percent improvement at 6 mos for KA was 51 (35) and for HA was 42 (33) (P = 0.51). Synvisc-One group visual analog scale scores improved significantly (70 [20]–45 [25] at 1 mo, P = 0.008). Pain Disability Questionnaire scores improved at 1 mo (100 [23]–77 [30], P = 0.009) in the KA group and at all time points in the HA group (102 [28]–74 [34] at 1 mo, P = 0.002; 74 [36] at 3 mos, P = 0.037; 79 at 6 mos [median = 52–99.5], P < 0.001). Medians and quartiles were used in statistical analysis when data did not pass normality. Conclusions Patients with chronic low back pain suggestive of lumbar lumbar zygopophyseal joint arthropathy responded similarly to triamcinolone or hyaluronate injections. Synvisc-One group showed significant short- and long-term functional improvement and short-term pain improvement; KA group showed only significant short-term functional benefit and no significant short- or long-term pain improvement.

Triamcinolone vs. Hyaluronate Injections for Lumbar Facet Arthropathy: A Pragmatic, Double Blind Randomized Controlled Trial

above (n1⁄4407). A second sample of 2034 subjects was randomly selected to assess the association of gender (female 1⁄4 1015, male 1⁄4 1019) with the NRS. A final sample of 1823 subjects was randomly selected to assess the association of depression (subjects with depression 1⁄4 911, subjects without depression 1⁄4 912) with the NRS. Interventions: Not applicable. Main Outcome Measures: Pain perception using Pain Numeric Rating Scale (NRS) of 0 to 10 (low pain perception: 0-3, moderate pain: 4-6 high pain perception: 7-10). Results or Clinical Course: An ordinal regression and Spearman correlation using SPSS V22 found that people who are 60 years and older are more likely to have low pain perception in comparison to people who are 18 to 59 years old (P1⁄4.000, P1⁄4.001). Furthermore, an ordinal regression also found that females are more likely than men to have high pain perception (P1⁄4.000). Finally, an ordinal regression found that patients with depression were more likely than patients without depression to have high pain perception (P1⁄4.000). Conclusion: This study suggests that age, gender, and depression may play a role in pain perception. Findings in this study will hopefully help to shed light on the complex factors affecting pain perceptions and help physicians make decisions regarding the pain management of patients.

Approaches to the Quantitative Physical and Functional Capacity Assessment of Occupational Musculoskeletal Disorders

In this chapter, we consider the objective characteristics that would be needed for an ideal assessment of worker physical and functional capacities. We review the pertinent clinical literature relating to quantitative assessment of physical capacity and function in the injured worker setting, from 1999 to 2012, and draw conclusions about the usefulness, if any, of these tests in the current environment. We also examine some recent findings from the physiology literature that may shed light on future improvements.

Poster 411 Prospective Correlation Analysis of Short-Form McGill Pain Questionnaire and Brief Pain Inventory Among Hospitalized, Lower Income Hispanic Patients in North Texas

option. NSAIDs showed mild to severe gastrointestinal complications after a long period of use. 13 about opioids found that tramadol associated with paracetamol (37.5/325 mg) had the same outcome as tramadol alone (50 mg) with fewer side effects. 3 with antidepressants such as tricyclic antidepressants and dual, showed better results than selective reuptake inhibitors of serotonin. Muscle relaxants were not considered as first-line therapy. Diathermy is not effective over long periods of time without concomitant therapeutic exercise. Also, therapeutic exercise improves low back pain; there is no evidence to support exercise preventing the recurrences of pain. Acupuncture combined with other conservative therapies is more beneficial. Conclusions: Drugs, electrical stimulation, exercise, and physical therapy treatments associated with exercise are options for the treatment of non-specific chronic low back pain. Acupuncture is associated with increased cost for the treatment of non-specific back pain, but it is recommended (10 sessions, two times per week) improving the quality of life with decreased absenteeism. Acupuncture plus routine care, resulted in a clinically relevant benefit and it is cost-effective among patients with low back pain.