- Email: [email protected]
(386) Medial Foot Column Disorders (Morton's and Rothbart's): Endemic, Underdiagnosed, and Undertreated
Abstracts
S70 The Journal of Pain suggest that yoga therapy, as an adjunct to traditional analgesic therapy, can be an efficacious tool in the management of chronic pain. Further randomized, controlled trials are needed to confirm our conclusions.
Molecular and Cellular Biology (with CE) (383) Loss of Gnb5 in Sensory Neurons Leads to Decreased Nociceptive but not Pruriceptive Stimuli in Mice M. Pandey, J. Zhang, P. Adikaram, N. Lue, C. Kittock, C. Chen, and W. Simonds; National Institute of Diabetes and Digestive and Kidney Diseases/ National Institutes of Health Pain and itch are two somatosensory modalities whose pathologic manifestations cause immense suffering and health burden to millions of people worldwide. Mu-opioid ligands and analogs have been the mainstream therapy against pain, but due to their significant side effects there is an urgent need to have a deeper understanding of the signaling of opioid receptors and to identify newer drug targets which could help improve treatment for these pathologies. Gb5 is a divergent member of the Gb subunits of heterotrimeric G proteins which are unique in binding the Gg like domain present in the R7- RGS proteins. This protein complex acts as a GTPase accelerating protein which terminates Gai/o signaling, thereby tightly controlling the signaling. Sensory neurons express several Gi/o coupled receptors which have been targeted for analgesia in pathologic pain. Using in situ hybridization and immunoblotting, we document the presence of Gb5 protein in sensory neurons. Since the Gb5 protein complex act as a GAP for Gi/o coupled GPCRs, its loss-of-function would be predicted to increase inhibitory signaling in sensory neurons leading a decreased pain or itch sensation. Using sensory neuron specific Advillin Cre mice we knocked down the expression of Gnb5 in sensory ganglia in floxed Gnb5 mice. The Adv Cre-Gnb5 fl/fl mice had a decreased nociceptive sensation for different pain modalities but not itch. Specific nociceptive changes could be blocked by the opioid antagonist, naltrexone or the GABAB antagonist, Saclofen indicating that Gb5 protein complex could be modulating different Gi/o coupled receptors involved in perceiving different modalities of pain perception. Further analysis of nociceptive stimuli in RGS7 Cre-Gnb5 fl/fl and RGS9 Cre-Gnb5 fl/fl mice revealed significant selective responses to different modalities indicating the role of different R7-RGS partners in pain signaling.
Treatment Approaches (Complementary & Alternative) (with CE) (384) Seeking Treatment for TMDs: What Patients Can Expect from Non-Dental Healthcare Providers A. Bertagna, and C. Greene; The University of Illinois at Chicago College of Dentistry The dental profession has long been the primary source for clinical management of patients with temporomandibular disorders (TMDs). However, patients with a facial pain problem may seek diagnosis and/or treatment from other healthcare providers. These providers may be physicians or other doctoral-level practitioners, or they could be members of various allied groups such as physical therapists, occupational therapists, acupuncturists, etc. However, little has been written about what patients might experience if they seek out care on their own outside of the dental profession. Initially, we conducted web searches targeted at the official websites of non-dental health professions who might see a TMD patient − either from referral or from primary presentation. Using various search terms, we searched for statements or published articles indicating their professional interest in TMDs. A google search for the websites of private practitioners in each of the non-dental professions was then conducted to see if individual providers were advertising TMD management. Most of the official websites had little or no information about TMDs, but some members of every group surveyed were offering to treat TMD in their offices. The variety of treatments being offered went far beyond the boundaries of appropriate TMD
management in the 21st century. These results are presented with a critical discussion of each concept or practice, and advice for patients to deal with this situation. Despite the generally negative findings, physical therapy emerged as the only ancillary health profession with standardized curriculum on TMJ/D and their management. Therefore, we advocate that when considering non-dental management dentists should refer only to physical therapists with specialized training in head and neck therapy. Furthermore, we emphasize primary referral to dentists with certified post-doctoral training in TMD/orofacial pain prior to considering non-dental options.
Treatment Approaches (Medical/ Interventional) (with CE) (385) The Evaluation of Blended Codeine Phosphate with Hydroxyzine Pamoate, Gabapentin, Ondansetron, and Docusate for the Treatment of Chronic Pain: A PatientCentered Approach to the Pain Management “State of Emergency” D. Bonner; LoMed Pain Management The United States is suffering from a so-called opioid epidemic. It has been proposed that the onset of this epidemic occurs in physician offices. In November 2016, the Centers for Disease Control published guidelines for the treatment of non-cancer related pain. In this guideline, they suggested limitations as to the amount of morphine milligram equivalencies that are allowed for adequate pain relief, while limiting the complication rate. In this study, we evaluate the effectiveness of a Codeine preparation for the treatment of moderate to severe pain. The study evaluates the effectiveness of reducing MME through substituting medication with a low MME rather than weaning the patient. A trial of 20 patients was carried out. The patients were required to score their pain while on their previous medications. The score was the standardized one -10/10 methodology. The patients were then switched to a Codeine blended therapy and were asked to report on their pain, using the same methodology. The effectiveness of this treatment program is presented. P values are calculated. Of the 20 patients, 19 had excellent results with equal pain relief and no significant adverse reactions. The use of a blended codeine therapy can lower the MME without change in pain or withdrawal.
(386) Medial Foot Column Disorders (Morton’s and Rothbart’s): Endemic, Underdiagnosed, and Undertreated R. Hartz, and M. Biancalana; CCMPR (Chicago Center for Myofascial Pain Relief) From Sept. 2016-Sept. 2018, 214 consecutive pats underwent a complete evaluation by both an MD and a Board Certified Myofascial Trigger point Therapist at one pain clinic. Of the 214, 133 pts (62%) had a medial foot column disorder ranging form Morton’s Toe (short first metatarsal or primus metatarsus elevatus) to Rothbart’s Foot (incomplete unwinding of talus). The most common complaints of the 133 pts were back pain in 37 and leg, knee, or hip pain in 29. Only 14 pts had foot pain, 5 of whom also had peripheral neuropathy. The mean age of pts was 52 yrs (13-81) and the female to male ratio was 3:1. The first metatarsal deficit (FMD) was measured using Rothbart’s microwedges with the foot in subtalar neutral position. Ten pts had an FMD up to 14 mm and were considered to have mild Morton’s Toe deformity. The other 123 pts (92%) had an FMD > 14 mm and were diagnosed with Rothbart’s Foot Structure, all of whom also had a short first metatarsal. In the latter group 3 pts had an FMD > 20mm, consistent with pre-clinical clubfoot disorder. Pts were treated with antipronation posture congtrol insoles (PCIs 3.5, 6,or 9mm depending on FMD). Arch suppports and heel lifts were added if leg length discrepancy or pes planus was present. Medial foot column disorders are extremely common and lead to callouses, bunions, neuromas, hammer toes and even knee and hip arthritis. We are unaware of any commercial shoe or orthotic that can remedy hyperpronation at the forefoot as well as can inexpensive PCIs. No pain/posture evaluation is complete without a barefoot, standing evaluation of the feet. Earlier diagnosis and treatment of these disorders is mandatory, especially in children and athletes, in order to avoid complications
The Journal of Pain requiring surgical intervention.
(387) Opioid Prescribing Patterns in Acute Inpatient Rehabilitation A. Glinka Przybysz, Z. Khudeira, J. Jacobs, K. Machino, and M. Gittler; Schwab Rehabilitation Hospital Mortality associated with opioids continues to rise. According to the CDC’s latest reports, in 2017 there were a total of 47,600 opioid-related overdose deaths, compared with 42,250 from 2016 resulting in increases in mortality across all ages, racial, ethnic groups and geographic regions. [1] The research literature and news media have described the role of different aspects of the medical community in this crisis. [2,3] Medical specialties have evaluated prescribing patterns for different physician specialities, demonstrating that PM&R physicians prescribe opioids at one of the highest rates. [4] The purpose of this study is to describe the opioid prescribing patterns of physical medicine and rehabilitation physicians in acute inpatient rehabilitation (AIR). Using a retrospective, cross-sectional study design, opioid prescription orders placed between July 1st 2017 and July 1st 2018 were reviewed at a single free-standing acute inpatient rehabilitation hospital in Chicago, IL. Descriptive data was analyzed using R statistical software (version R-3.5.2). There were a total of 1,266 inpatient opioid medication orders written (out of a total of 28,301 medication orders for all drugs). There were 480 patients who received these prescriptions. Seven different types of opioid pain medications were prescribed: hydrocodone-acetaminophen (APAP), oxycodone, methadone, morphine, hydromorphone, fentanyl, and tramadol which were prescribed in 24 different dosing formulations (i.e. Norco 5 mg vs. 10 mg or liquid vs. tab). There were 692 (54.7%) hydrocodoneAPAP prescriptions, 395 (31.2%) tramadol, 80 (6.3%) oxycodone, 33 (2.6%) methadone, 27 (2.1%) morphine, 23 (1.8%) hydromorphone, and 16 (1.3%) fentanyl. The composite opioid prescribing rate for 2017-2018 in AIR is 4.5%. This project is the first step in a larger quality improvement project evaluating analgesic prescribing in AIR among physical medicine and rehabilitation physicians. References [1] Scholl L. Drug and Opioid-Involved Overdose Deaths − United States, 2013−2017. MMWR Morb Mortal Wkly Rep 2019;67:1419 −1427. [Accessed 1/13/2019] [2] Quinones, S. Dreamland: the True Tale of America’s Opiate Epidemic. Bloomsbury YA, 2015. [3] Bohnert ASB. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA. 2011;305(13):1315−1321. doi:10.1001/jama.2011.370 [4] Levy B. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007−2012. Am J Prev Med. 2015;49(3):409−41
Treatment Approaches (Psychological & Rehabilitative) (with CE) (155) Personalized Activated Care and Training: A PACT with Patients to Prevent Chronic Pain and Addiction J. Fricton; HealthPartners Institute PURPOSE: The Institute of Medicine states that a health professionals’ primary role for chronic pain should be guiding, coaching, and assisting patients with day-to-day self-management. However, providers often lack the time and training to perform this role, and there is limited research on self-management approaches. We propose providers use a transformative care model that integrates robust patient training with evidence-based treatments using telecoaching and technology to improve long-term outcomes and health chronic pain. METHODS: The Personalized Activated Care and Training (PACT) program was developed to enhance understanding, compliance, and success in self-management of pain conditions and includes risk assessment, on-line risk reduction training, and tele-health coaching to reduce risk factors that contribute to delayed recovery and implement protective actions to reduce chronic pain. We conducted a pilot RCT to refine the program, evaluate evaluate preliminary efficacy at 8 and 16 weeks and feasibility for broad scale implementation. RESULTS: Eighty-one subjects were randomized to PACT and Usual care and survey measures were obtained. Cohen’s -d statistic
S71
was estimated for survey outcomes and a subset of participants were interviewed regarding their experiences. Participants had a mean age of 46 (PACT), 49 (TSC) and the majority were white and female. Outcomes at 16 weeks in patients with head and neck pain showed improvement in the PACT group relative to UC on measures of pain severity (PACT: 1.22, UC: -.74), pain interference in daily living (PACT: -.49, UC: -.27), and chronic pain self-efficacy (PACT: .45, UC: .27). CONCLUSION: This research demonstrated that transformative care model that includes tele-health coaching and on-line training is both feasible and effective. It provides an accessible, scalable, and transferable method for self-management that can be integrated into routine care without increasing the burden of time demands upon the providers. PACT was developed and tested with grants from NIH/NIDCRU01DE025609.
(388) Multidisciplinary "Prehab" Prior to Spine Surgery for Patients with Opioid Addiction and Chronic Pain Syndrome is Efficacious S. Pourtaheri, M. Herbert, M. Patek, M. Parikh, and D. Baker; UCSD Opioid addiction is the number one health care issue in the United States with spinal ailments the leading medical condition associated with opioid addiction. In the literature, patients with chronic pain syndrome and opioid addiction going for spine surgery have poor post-operative clinical outcomes and likely to be on opioids for life. Current evidence-based methods to optimize patients prior to spine surgery have been: 1) transition from opioids to non-opioid medications, 2) cardiovascular exercise program, 3) smoking cessation, 4) alcohol cessation, and 5) psychotherapy to treat mood and maladaptive pain behavior. The authors hypothesized that an initiation of an interdisciplinary “prehab” protocol utilizing all five aforementioned modalities prior to spine surgery in patients with chronic pain syndrome and opioid addiction would optimize postsurgical outcomes, including decreased pain and opioid consumption. From 2013 to 2017, 175 patients (85 without prehab, 89 with prehab) met the inclusion criteria. Demographics and case breakdown (surgery type performed) were similar between the cohorts. One year after surgery, a significantly greater amount of patients receiving prehab were opioid-free following surgery compared to patients without prehab (28% vs 92%, respectively, p<0.0001). Furthermore, pain relief was greater in those receiving prehab. Improvement in axial pain (VAS neck/back pain) and radiculopathy (VAS arm/leg pain) were both two-fold greater in patients with prehab compared to those without prehab (p<0.001, p<0.001, respectively). Patients receiving prehab also had significant improvements in quality of life, depression, and pain acceptance compared to those without prehab (p<0.001, p<0.001, p<0.0001). A multidisciplinary “prehab” program for patients with opioid addiction and chronic pain syndrome going for spine surgery is efficacious at reducing opioid addiction and pain, improving quality of life and depression, and forging a healthier relationship with pain.
(389) Pediatric Impression of Change following Interdisciplinary Treatment C. Gagnon, L. Henderson, D. Amstutz, G. Revivo, and P. Scholten; Shirley Ryan AbilityLab This study assessed the utility of the Multidimensional Patient Impression of Change (MPIC) questionnaire in a pediatric pain population following interdisciplinary treatment. The MPIC assesses impression of change for seven clinical domains (Pain, Sleep, Mood, Physical Functioning, Coping with Pain, Managing Flare-up pain, Medication Efficacy) in addition to Overall Status. A heterogeneous group of pediatric chronic pain patients (N = 202) participated in an interdisciplinary treatment program. Treatment programs included individual psychological counseling, relaxation training, physical therapy, occupational therapy, and physician management. Patients completed measures assessing pain, mood, development, social and physical functioning, and family functioning both prior to and at completion of their treatment programs. The MPIC was administered to the patients post-treatment. The majority of patients perceived themselves to be improved (Minimally to Very Much) in all clinical domains of the MPIC. The proportion of patients endorsing improvement ranged from 60% (Medication Efficacy) to 96% (Coping with Pain). There were statistically significant pre- to post-treatment improvements on all outcome measures
S70 The Journal of Pain suggest that yoga therapy, as an adjunct to traditional analgesic therapy, can be an efficacious tool in the management of chronic pain. Further randomized, controlled trials are needed to confirm our conclusions.
Molecular and Cellular Biology (with CE) (383) Loss of Gnb5 in Sensory Neurons Leads to Decreased Nociceptive but not Pruriceptive Stimuli in Mice M. Pandey, J. Zhang, P. Adikaram, N. Lue, C. Kittock, C. Chen, and W. Simonds; National Institute of Diabetes and Digestive and Kidney Diseases/ National Institutes of Health Pain and itch are two somatosensory modalities whose pathologic manifestations cause immense suffering and health burden to millions of people worldwide. Mu-opioid ligands and analogs have been the mainstream therapy against pain, but due to their significant side effects there is an urgent need to have a deeper understanding of the signaling of opioid receptors and to identify newer drug targets which could help improve treatment for these pathologies. Gb5 is a divergent member of the Gb subunits of heterotrimeric G proteins which are unique in binding the Gg like domain present in the R7- RGS proteins. This protein complex acts as a GTPase accelerating protein which terminates Gai/o signaling, thereby tightly controlling the signaling. Sensory neurons express several Gi/o coupled receptors which have been targeted for analgesia in pathologic pain. Using in situ hybridization and immunoblotting, we document the presence of Gb5 protein in sensory neurons. Since the Gb5 protein complex act as a GAP for Gi/o coupled GPCRs, its loss-of-function would be predicted to increase inhibitory signaling in sensory neurons leading a decreased pain or itch sensation. Using sensory neuron specific Advillin Cre mice we knocked down the expression of Gnb5 in sensory ganglia in floxed Gnb5 mice. The Adv Cre-Gnb5 fl/fl mice had a decreased nociceptive sensation for different pain modalities but not itch. Specific nociceptive changes could be blocked by the opioid antagonist, naltrexone or the GABAB antagonist, Saclofen indicating that Gb5 protein complex could be modulating different Gi/o coupled receptors involved in perceiving different modalities of pain perception. Further analysis of nociceptive stimuli in RGS7 Cre-Gnb5 fl/fl and RGS9 Cre-Gnb5 fl/fl mice revealed significant selective responses to different modalities indicating the role of different R7-RGS partners in pain signaling.
Treatment Approaches (Complementary & Alternative) (with CE) (384) Seeking Treatment for TMDs: What Patients Can Expect from Non-Dental Healthcare Providers A. Bertagna, and C. Greene; The University of Illinois at Chicago College of Dentistry The dental profession has long been the primary source for clinical management of patients with temporomandibular disorders (TMDs). However, patients with a facial pain problem may seek diagnosis and/or treatment from other healthcare providers. These providers may be physicians or other doctoral-level practitioners, or they could be members of various allied groups such as physical therapists, occupational therapists, acupuncturists, etc. However, little has been written about what patients might experience if they seek out care on their own outside of the dental profession. Initially, we conducted web searches targeted at the official websites of non-dental health professions who might see a TMD patient − either from referral or from primary presentation. Using various search terms, we searched for statements or published articles indicating their professional interest in TMDs. A google search for the websites of private practitioners in each of the non-dental professions was then conducted to see if individual providers were advertising TMD management. Most of the official websites had little or no information about TMDs, but some members of every group surveyed were offering to treat TMD in their offices. The variety of treatments being offered went far beyond the boundaries of appropriate TMD
management in the 21st century. These results are presented with a critical discussion of each concept or practice, and advice for patients to deal with this situation. Despite the generally negative findings, physical therapy emerged as the only ancillary health profession with standardized curriculum on TMJ/D and their management. Therefore, we advocate that when considering non-dental management dentists should refer only to physical therapists with specialized training in head and neck therapy. Furthermore, we emphasize primary referral to dentists with certified post-doctoral training in TMD/orofacial pain prior to considering non-dental options.
Treatment Approaches (Medical/ Interventional) (with CE) (385) The Evaluation of Blended Codeine Phosphate with Hydroxyzine Pamoate, Gabapentin, Ondansetron, and Docusate for the Treatment of Chronic Pain: A PatientCentered Approach to the Pain Management “State of Emergency” D. Bonner; LoMed Pain Management The United States is suffering from a so-called opioid epidemic. It has been proposed that the onset of this epidemic occurs in physician offices. In November 2016, the Centers for Disease Control published guidelines for the treatment of non-cancer related pain. In this guideline, they suggested limitations as to the amount of morphine milligram equivalencies that are allowed for adequate pain relief, while limiting the complication rate. In this study, we evaluate the effectiveness of a Codeine preparation for the treatment of moderate to severe pain. The study evaluates the effectiveness of reducing MME through substituting medication with a low MME rather than weaning the patient. A trial of 20 patients was carried out. The patients were required to score their pain while on their previous medications. The score was the standardized one -10/10 methodology. The patients were then switched to a Codeine blended therapy and were asked to report on their pain, using the same methodology. The effectiveness of this treatment program is presented. P values are calculated. Of the 20 patients, 19 had excellent results with equal pain relief and no significant adverse reactions. The use of a blended codeine therapy can lower the MME without change in pain or withdrawal.
(386) Medial Foot Column Disorders (Morton’s and Rothbart’s): Endemic, Underdiagnosed, and Undertreated R. Hartz, and M. Biancalana; CCMPR (Chicago Center for Myofascial Pain Relief) From Sept. 2016-Sept. 2018, 214 consecutive pats underwent a complete evaluation by both an MD and a Board Certified Myofascial Trigger point Therapist at one pain clinic. Of the 214, 133 pts (62%) had a medial foot column disorder ranging form Morton’s Toe (short first metatarsal or primus metatarsus elevatus) to Rothbart’s Foot (incomplete unwinding of talus). The most common complaints of the 133 pts were back pain in 37 and leg, knee, or hip pain in 29. Only 14 pts had foot pain, 5 of whom also had peripheral neuropathy. The mean age of pts was 52 yrs (13-81) and the female to male ratio was 3:1. The first metatarsal deficit (FMD) was measured using Rothbart’s microwedges with the foot in subtalar neutral position. Ten pts had an FMD up to 14 mm and were considered to have mild Morton’s Toe deformity. The other 123 pts (92%) had an FMD > 14 mm and were diagnosed with Rothbart’s Foot Structure, all of whom also had a short first metatarsal. In the latter group 3 pts had an FMD > 20mm, consistent with pre-clinical clubfoot disorder. Pts were treated with antipronation posture congtrol insoles (PCIs 3.5, 6,or 9mm depending on FMD). Arch suppports and heel lifts were added if leg length discrepancy or pes planus was present. Medial foot column disorders are extremely common and lead to callouses, bunions, neuromas, hammer toes and even knee and hip arthritis. We are unaware of any commercial shoe or orthotic that can remedy hyperpronation at the forefoot as well as can inexpensive PCIs. No pain/posture evaluation is complete without a barefoot, standing evaluation of the feet. Earlier diagnosis and treatment of these disorders is mandatory, especially in children and athletes, in order to avoid complications
The Journal of Pain requiring surgical intervention.
(387) Opioid Prescribing Patterns in Acute Inpatient Rehabilitation A. Glinka Przybysz, Z. Khudeira, J. Jacobs, K. Machino, and M. Gittler; Schwab Rehabilitation Hospital Mortality associated with opioids continues to rise. According to the CDC’s latest reports, in 2017 there were a total of 47,600 opioid-related overdose deaths, compared with 42,250 from 2016 resulting in increases in mortality across all ages, racial, ethnic groups and geographic regions. [1] The research literature and news media have described the role of different aspects of the medical community in this crisis. [2,3] Medical specialties have evaluated prescribing patterns for different physician specialities, demonstrating that PM&R physicians prescribe opioids at one of the highest rates. [4] The purpose of this study is to describe the opioid prescribing patterns of physical medicine and rehabilitation physicians in acute inpatient rehabilitation (AIR). Using a retrospective, cross-sectional study design, opioid prescription orders placed between July 1st 2017 and July 1st 2018 were reviewed at a single free-standing acute inpatient rehabilitation hospital in Chicago, IL. Descriptive data was analyzed using R statistical software (version R-3.5.2). There were a total of 1,266 inpatient opioid medication orders written (out of a total of 28,301 medication orders for all drugs). There were 480 patients who received these prescriptions. Seven different types of opioid pain medications were prescribed: hydrocodone-acetaminophen (APAP), oxycodone, methadone, morphine, hydromorphone, fentanyl, and tramadol which were prescribed in 24 different dosing formulations (i.e. Norco 5 mg vs. 10 mg or liquid vs. tab). There were 692 (54.7%) hydrocodoneAPAP prescriptions, 395 (31.2%) tramadol, 80 (6.3%) oxycodone, 33 (2.6%) methadone, 27 (2.1%) morphine, 23 (1.8%) hydromorphone, and 16 (1.3%) fentanyl. The composite opioid prescribing rate for 2017-2018 in AIR is 4.5%. This project is the first step in a larger quality improvement project evaluating analgesic prescribing in AIR among physical medicine and rehabilitation physicians. References [1] Scholl L. Drug and Opioid-Involved Overdose Deaths − United States, 2013−2017. MMWR Morb Mortal Wkly Rep 2019;67:1419 −1427. [Accessed 1/13/2019] [2] Quinones, S. Dreamland: the True Tale of America’s Opiate Epidemic. Bloomsbury YA, 2015. [3] Bohnert ASB. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA. 2011;305(13):1315−1321. doi:10.1001/jama.2011.370 [4] Levy B. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007−2012. Am J Prev Med. 2015;49(3):409−41
Treatment Approaches (Psychological & Rehabilitative) (with CE) (155) Personalized Activated Care and Training: A PACT with Patients to Prevent Chronic Pain and Addiction J. Fricton; HealthPartners Institute PURPOSE: The Institute of Medicine states that a health professionals’ primary role for chronic pain should be guiding, coaching, and assisting patients with day-to-day self-management. However, providers often lack the time and training to perform this role, and there is limited research on self-management approaches. We propose providers use a transformative care model that integrates robust patient training with evidence-based treatments using telecoaching and technology to improve long-term outcomes and health chronic pain. METHODS: The Personalized Activated Care and Training (PACT) program was developed to enhance understanding, compliance, and success in self-management of pain conditions and includes risk assessment, on-line risk reduction training, and tele-health coaching to reduce risk factors that contribute to delayed recovery and implement protective actions to reduce chronic pain. We conducted a pilot RCT to refine the program, evaluate evaluate preliminary efficacy at 8 and 16 weeks and feasibility for broad scale implementation. RESULTS: Eighty-one subjects were randomized to PACT and Usual care and survey measures were obtained. Cohen’s -d statistic
S71
was estimated for survey outcomes and a subset of participants were interviewed regarding their experiences. Participants had a mean age of 46 (PACT), 49 (TSC) and the majority were white and female. Outcomes at 16 weeks in patients with head and neck pain showed improvement in the PACT group relative to UC on measures of pain severity (PACT: 1.22, UC: -.74), pain interference in daily living (PACT: -.49, UC: -.27), and chronic pain self-efficacy (PACT: .45, UC: .27). CONCLUSION: This research demonstrated that transformative care model that includes tele-health coaching and on-line training is both feasible and effective. It provides an accessible, scalable, and transferable method for self-management that can be integrated into routine care without increasing the burden of time demands upon the providers. PACT was developed and tested with grants from NIH/NIDCRU01DE025609.
(388) Multidisciplinary "Prehab" Prior to Spine Surgery for Patients with Opioid Addiction and Chronic Pain Syndrome is Efficacious S. Pourtaheri, M. Herbert, M. Patek, M. Parikh, and D. Baker; UCSD Opioid addiction is the number one health care issue in the United States with spinal ailments the leading medical condition associated with opioid addiction. In the literature, patients with chronic pain syndrome and opioid addiction going for spine surgery have poor post-operative clinical outcomes and likely to be on opioids for life. Current evidence-based methods to optimize patients prior to spine surgery have been: 1) transition from opioids to non-opioid medications, 2) cardiovascular exercise program, 3) smoking cessation, 4) alcohol cessation, and 5) psychotherapy to treat mood and maladaptive pain behavior. The authors hypothesized that an initiation of an interdisciplinary “prehab” protocol utilizing all five aforementioned modalities prior to spine surgery in patients with chronic pain syndrome and opioid addiction would optimize postsurgical outcomes, including decreased pain and opioid consumption. From 2013 to 2017, 175 patients (85 without prehab, 89 with prehab) met the inclusion criteria. Demographics and case breakdown (surgery type performed) were similar between the cohorts. One year after surgery, a significantly greater amount of patients receiving prehab were opioid-free following surgery compared to patients without prehab (28% vs 92%, respectively, p<0.0001). Furthermore, pain relief was greater in those receiving prehab. Improvement in axial pain (VAS neck/back pain) and radiculopathy (VAS arm/leg pain) were both two-fold greater in patients with prehab compared to those without prehab (p<0.001, p<0.001, respectively). Patients receiving prehab also had significant improvements in quality of life, depression, and pain acceptance compared to those without prehab (p<0.001, p<0.001, p<0.0001). A multidisciplinary “prehab” program for patients with opioid addiction and chronic pain syndrome going for spine surgery is efficacious at reducing opioid addiction and pain, improving quality of life and depression, and forging a healthier relationship with pain.
(389) Pediatric Impression of Change following Interdisciplinary Treatment C. Gagnon, L. Henderson, D. Amstutz, G. Revivo, and P. Scholten; Shirley Ryan AbilityLab This study assessed the utility of the Multidimensional Patient Impression of Change (MPIC) questionnaire in a pediatric pain population following interdisciplinary treatment. The MPIC assesses impression of change for seven clinical domains (Pain, Sleep, Mood, Physical Functioning, Coping with Pain, Managing Flare-up pain, Medication Efficacy) in addition to Overall Status. A heterogeneous group of pediatric chronic pain patients (N = 202) participated in an interdisciplinary treatment program. Treatment programs included individual psychological counseling, relaxation training, physical therapy, occupational therapy, and physician management. Patients completed measures assessing pain, mood, development, social and physical functioning, and family functioning both prior to and at completion of their treatment programs. The MPIC was administered to the patients post-treatment. The majority of patients perceived themselves to be improved (Minimally to Very Much) in all clinical domains of the MPIC. The proportion of patients endorsing improvement ranged from 60% (Medication Efficacy) to 96% (Coping with Pain). There were statistically significant pre- to post-treatment improvements on all outcome measures