- Email: [email protected]
Poster 155
E32
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
extremity but had persistent anterior thigh pain and proximal weakness. 9 months later, she complained of increased left anterior thigh pain. Left-sided hip flexor and quadriceps muscles were weak, and popliteal and dorsalis pedis pulses were decreased. Brachial pedal index suggested left femoral artery stenosis. CT of the retroperitoneum was obtained to rule out nerve root, lumbar plexus, or peripheral nerve compression and revealed a mass along the left iliopsoas muscle. Arteriogram revealed a large false aneurysm that communicated with the left common femoral artery. Surgery to resect the aneurysm revealed exposed parts of the hip replacement which may have contributed to the aneurysm. Assessment/Results: Femoral nerve compression by a retroperitoneal false aneurysm. Discussion: This case highlights the importance of considering retroperitoneal pathology in the differential diagnosis of anterior thigh pain and weakness. The theoretical role that the THA may have played in the development of the patient’s false aneurysm is discussed. Conclusions: Imaging of the retroperitoneum should be considered in any patient presenting with anterior thigh pain and weakness. Key Words: Aneurysm, false; Femoral neuropathy; Pain; Rehabilitation.
Pain Rehabilitation Poster 152: Cancelled.
Poster 153 Sleep Disturbance in Chronic Low Back Pain Patients. Raul Marin, LTC(P), MC, FS; Tamara Cyhan, RN, BSN; Wendy Miklos, MD; Raul Marin, LTC(P), MC, FS (Walter Reed Army Medical Center, Washington, DC), e-mail: [email protected]. Disclosure: None. Objective: To document the relationship of sleep disturbances in chronic low back (CLBP), patients referred to a physical medicine and rehabilitation clinic. Design: Prospective cross-sectional survey. Setting: Tertiary U.S. military medical center. Participants: Convenience sample of military beneficiaries 18 years or older being evaluated for low back pain of ⬎6 months in duration. Interventions: Not applicable. Main Outcome Measures: A 43-item composite survey form was used containing the Short-Form McGill Pain Questionnaire (SF-MPQ); the Pittsburgh Sleep Quality Index (PSQI); a pain visual analog scale (VAS); and questions on bed type, sleep position, and patients’ sleep description. Results: There was a significant relationship between pain and sleep (P⬍.001) with a 55% increase in the proportion of subjects reporting restless/light sleep after pain onset. There was no corresponding increase in sleep medication use. There was a significant direct correlation between SF-MPQ and PSQI (r⫽.44, P⬍.001); between PSQI and VAS (r⫽.41, P⬍.001) and between overall quality of sleep (component of PSQI) and VAS (r⫽.31, P⬍.001). Finally, PSQI scores were the worst in subjects sleeping on an orthopedic mattress (P⫽.001). Conclusions: CLBP significantly affects quality of sleep. Sleep problems should be addressed as an integral part of the pain management plan. Key Words: Low back pain; Chronic disease; Dyssomnias; Rehabilitation.
Poster 154 Buprenorphine Transdermal System in Chronic Pain Due to Osteoarthritis. Michael J. Shannon, PhD (Purdue Pharma LP, Stamford, CT); Alan J. Kivitz, MD; Craig J. Landau, MD; Nelson E. Sessler, PharmD; Yichaun Xia, PhD; Steven R. Ripa, MD, e-mail: [email protected]. Disclosure: Shannon, Purdue Pharma L.P. employee; Kivitz, Altoona Center for Clinical Research employee; Landau, Purdue Pharma L.P. employee; Sessler, Purdue Pharma L.P. employee; Xia, Purdue Pharma L.P. employee; Ripa, Purdue Pharma L.P. employee. Objective: To evaluate the safety and efficacy of the buprenorphine transdermal system (BTDS) compared with placebo in subjects with chronic pain due to osteoarthritis (OA) of the hip and knee. Design: Randomized, double-blind, placebo-controlled, maintenance-of-analgesia design study consisting of 3 phases: open-label run-in (21d), double-blind evaluation (28d), and open-label extension (6mo). Setting: 41 outpatient centers in the U.S. Participants: 326 subjects age 36 to 79 with OA for ⱖ1 year, currently treated with stable doses of nonopioid analgesics or intermittent doses of opioid and nonopioid analgesics. Subjects reported moderate to severe pain during the 14 days prior to enrollment. Intervention: Open-label run-in: subjects were titrated to a dose of BTDS (5mg, 10mg, or 20mg) that provided adequate analgesia with acceptable tolerability. Double-blind evaluation: subjects meeting protocol-specified criteria for “adequate analgesia” were randomized to BTDS or placebo. Subjects continued taking their prestudy chronic, stable nonopioid analgesics, discontinued all intermittent analgesics, and were provided acetaminophen for breakthrough pain. Main Outcome Measures: Time to development of inadequate analgesia; mean daily maximum “pain right now” scores over last 7 days of study drug treatment. Results: The median time to inadequate analgesia was 7 days in placebo versus 21 days in BTDS-treated subjects (P⫽.003). In total, 66% of placebo and 51% of BTDS-treated subjects met the protocol-specified criteria for inadequate analgesia. Mean daily maximum “pain right now” scores were lower in BTDS (3.2⫾0.14) compared with placebo-treated subjects (3.8⫾0.15, P⫽.007). Adverse events reported were those typically observed with other opioids. No clinically important changes in labs, electrocardiograms, or vitals were noted. Conclusions: BTDS had significantly better efficacy than placebo and was generally well tolerated supporting the benefits of BTDS in patients with chronic pain due to OA of the hip and knee. Key Words: Buprenorphine; Chronic pain; Rehabilitation; Transdermal administration.
Poster 155 Effects of Nonsteroidal Anti-Inflammatory Drugs on Histologic Change of the Achilles’ Tendon in Experimental Prolotherapy Model. Kang Sik Lee, Resident; Hyun Jung Kim, Professor; Dong Hwan Yun, Professor; Se Hoon Kim, Professor (Eulji Hospital, Eulji University School of Medicine, Seoul, Republic of Korea), e-mail: [email protected]. Disclosure: None.
Arch Phys Med Rehabil Vol 86, September 2005
Objective: To investigate the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen on histologic change of the Achilles’ tendon of rats for pain control during prolotherapy. Design: Prospective, experimental, randomized controlled study. Setting: Laboratory animal facility. Animals: 60 adult male Sprague-Dawley rats (weight range, 500 –550g). Intervention: The right Achilles’ tendon of rats was injected with 20% dextrose in day 1, day 7, and day 14. Rats were divided into 3 subgroups: celecoxib medication group (10mg䡠kg⫺1䡠d⫺1), acetaminophen medication group (100mg䡠kg⫺1䡠d⫺1), and control group. Medications were given during consecutive 3 days after each injection. Rats were sacrificed at 3 weeks and 6 weeks after first injection of prolotherapy. Gross and histologic evaluation of both Achilles’ tendon were performed. Main Outcome Measures: The transverse diameter of both Achilles’ tendon, the number of fibroblasts on light microscope (⫻400), and the distribution of fibril diameters on electron microscope were assessed. The Wilcoxon signed-rank test and Kruskal-Wallis test was used for statistical analysis, with Pⱕ.05 considered statistically significant. Results: The transverse diameter and the count of fibroblasts of all group increased significantly in the injected tendon compared with the noninjected tendon. However, there were no statistically significant differences among all groups (all P⬎.05). On electron micrograph, the fibrill diameters of injected tendon consisted of mainly smaller sizes with the intermediate sizes. Conclusions: An increase in the transverse diameter and the number of fibroblasts of injected tendon suggests that prolotherapy enhances fibroblastic stimulation and the elaboration of extracellular matrix. This study supports the use of NSAIDs is acceptable for pain relief during prolotherapy if glucose is used for proliperant. Key Words: Prolotherapy; Rehabilitation; Tendon.
Poster 156 Botulinum Toxin Type A Versus Bupivacaine Trigger Point Injections for the Treatment of Myofascial Pain Syndrome: A Randomized Double Blind Crossover Study. Corrie L. Graboski, MD (University of Alberta, Edmonton, AB, Canada); Shaun Gray, MD, PhD; Robert S. Burnham, MD, MSc, e-mail: [email protected]. Disclosure: None. Objective: To compare the effectiveness of trigger point injections using botulinum toxin type A (BTX-A) or bupivacaine in combination with a home-based exercise program in patients with myofascial pain syndrome. Design: Double-blind, crossover trial. Setting: Community physiatry practice. Participants: 18 patients with myofascial pain syndrome recruited by family physician or physiatrist. Intervention: Subjects were randomly assigned to receive initial injections of either 25U of BTX-A per trigger point or bupivacaine injections. A maximum of 8 trigger points were injected per subject. Subjects were followed until their pain returned to 75% of their preinjection pain after which there was a 2 week wash-out period. The subjects then had the same trigger points injected with the other agent. All subjects participated in a home exercise program involving static stretches of the affected muscles. Main Outcome Measures: Magnitude and duration of pain relief, effect on functional ability, satisfaction, and cost savings. Results: Both treatments were effective in reducing pain when compared with baseline (P⬍.05). There was, however, no significant difference between the BTX-A and bupivacaine groups in number of weeks of pain relief, magnitude of pain relief, cost savings, function, or satisfaction. Conclusions: Although both BTX-A and bupivacaine injections were effective, there was no benefit to the use of BTX-A over bupivacaine in the treatment of myofascial pain. In view of the significantly high cost of BTX-A, it is difficult to recommend this agent as a first line intervention in this condition. Key Words: botulinum toxin type A; Rehabilitation; Trigger point.
Poster 157 A New Validated Patient-Completed Neuropathic Pain Screening Tool for Use in the Primary Care Setting. R.K. Portenoy; C. Cleeland; M. Backonja; R. Moskowitz; L. McLeod; T. Griesing (Pfizer Global Pharmaceuticals, Pfizer Inc, New York, NY), e-mail: [email protected]. Disclosure: Portenoy, Consultant for Pfizer Inc; Backonja, Research grant from Pfizer Inc., Consultant for Pfizer Inc.; McLeod, Consultant for Pfizer Inc; Griesing, Pfizer Inc. employee. Objective: To develop and validate a patient-completed screening tool capable of differentiating nociceptive and neuropathic pain in primary care settings. Design: The screening tool was created using data from patients visiting general practitioners (development study) and then validated against data from a 2nd group of chronic pain patients visiting pain specialist offices (validation study). In the development study, patients with nonheadache, chronic pain completed an 89-item chronic-pain questionnaire and were then referred to pain specialists for diagnosis (benchmark). Factor- and univariate-regression analyses combined with input from a panel of experts were used to derive the set of questions comprising the screening tool from the 89 potential items. The tool’s sensitivity and specificity were assessed first against data from the development study and then against data from the validation study. Setting: Multiple clinical research centers in the U.S. Participants: Adults with nonheadache chronic pain ⱖ30 days. Interventions: Not applicable. Main Outcome Measures: Sensitivity, specificity, and concordance of screening tool. Results: In the development study, 586 patients completed the chronic-pain questionnaire. 6 items from the 89-item questionnaire were selected to form the screening tool (scores, ⫺1 to 5). These items identified nearly 70% of neuropathic pain patients as being “likely” or “very likely” to have pain with a neuropathic component, whereas only 25% of nociceptive patients were similarly classified. In the validation study, the tool’s sensitivity, specificity, and concordance were investigated against 308 patients. Experts identified 105, 99, and 104 patients as having neuropathic, nociceptive, and mixed pain. The tool exhibited a .69 concordance index, consistent with findings from the development study. Conclusions: We developed and validated a promising instrument that can aid primary care professionals in estimating the likelihood that a chronic-pain patient may be experiencing neuropathic pain. Key Words: Neuropathic pain; Pain treatment; Primary care; Rehabilitation; Screening tool.
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
extremity but had persistent anterior thigh pain and proximal weakness. 9 months later, she complained of increased left anterior thigh pain. Left-sided hip flexor and quadriceps muscles were weak, and popliteal and dorsalis pedis pulses were decreased. Brachial pedal index suggested left femoral artery stenosis. CT of the retroperitoneum was obtained to rule out nerve root, lumbar plexus, or peripheral nerve compression and revealed a mass along the left iliopsoas muscle. Arteriogram revealed a large false aneurysm that communicated with the left common femoral artery. Surgery to resect the aneurysm revealed exposed parts of the hip replacement which may have contributed to the aneurysm. Assessment/Results: Femoral nerve compression by a retroperitoneal false aneurysm. Discussion: This case highlights the importance of considering retroperitoneal pathology in the differential diagnosis of anterior thigh pain and weakness. The theoretical role that the THA may have played in the development of the patient’s false aneurysm is discussed. Conclusions: Imaging of the retroperitoneum should be considered in any patient presenting with anterior thigh pain and weakness. Key Words: Aneurysm, false; Femoral neuropathy; Pain; Rehabilitation.
Pain Rehabilitation Poster 152: Cancelled.
Poster 153 Sleep Disturbance in Chronic Low Back Pain Patients. Raul Marin, LTC(P), MC, FS; Tamara Cyhan, RN, BSN; Wendy Miklos, MD; Raul Marin, LTC(P), MC, FS (Walter Reed Army Medical Center, Washington, DC), e-mail: [email protected]. Disclosure: None. Objective: To document the relationship of sleep disturbances in chronic low back (CLBP), patients referred to a physical medicine and rehabilitation clinic. Design: Prospective cross-sectional survey. Setting: Tertiary U.S. military medical center. Participants: Convenience sample of military beneficiaries 18 years or older being evaluated for low back pain of ⬎6 months in duration. Interventions: Not applicable. Main Outcome Measures: A 43-item composite survey form was used containing the Short-Form McGill Pain Questionnaire (SF-MPQ); the Pittsburgh Sleep Quality Index (PSQI); a pain visual analog scale (VAS); and questions on bed type, sleep position, and patients’ sleep description. Results: There was a significant relationship between pain and sleep (P⬍.001) with a 55% increase in the proportion of subjects reporting restless/light sleep after pain onset. There was no corresponding increase in sleep medication use. There was a significant direct correlation between SF-MPQ and PSQI (r⫽.44, P⬍.001); between PSQI and VAS (r⫽.41, P⬍.001) and between overall quality of sleep (component of PSQI) and VAS (r⫽.31, P⬍.001). Finally, PSQI scores were the worst in subjects sleeping on an orthopedic mattress (P⫽.001). Conclusions: CLBP significantly affects quality of sleep. Sleep problems should be addressed as an integral part of the pain management plan. Key Words: Low back pain; Chronic disease; Dyssomnias; Rehabilitation.
Poster 154 Buprenorphine Transdermal System in Chronic Pain Due to Osteoarthritis. Michael J. Shannon, PhD (Purdue Pharma LP, Stamford, CT); Alan J. Kivitz, MD; Craig J. Landau, MD; Nelson E. Sessler, PharmD; Yichaun Xia, PhD; Steven R. Ripa, MD, e-mail: [email protected]. Disclosure: Shannon, Purdue Pharma L.P. employee; Kivitz, Altoona Center for Clinical Research employee; Landau, Purdue Pharma L.P. employee; Sessler, Purdue Pharma L.P. employee; Xia, Purdue Pharma L.P. employee; Ripa, Purdue Pharma L.P. employee. Objective: To evaluate the safety and efficacy of the buprenorphine transdermal system (BTDS) compared with placebo in subjects with chronic pain due to osteoarthritis (OA) of the hip and knee. Design: Randomized, double-blind, placebo-controlled, maintenance-of-analgesia design study consisting of 3 phases: open-label run-in (21d), double-blind evaluation (28d), and open-label extension (6mo). Setting: 41 outpatient centers in the U.S. Participants: 326 subjects age 36 to 79 with OA for ⱖ1 year, currently treated with stable doses of nonopioid analgesics or intermittent doses of opioid and nonopioid analgesics. Subjects reported moderate to severe pain during the 14 days prior to enrollment. Intervention: Open-label run-in: subjects were titrated to a dose of BTDS (5mg, 10mg, or 20mg) that provided adequate analgesia with acceptable tolerability. Double-blind evaluation: subjects meeting protocol-specified criteria for “adequate analgesia” were randomized to BTDS or placebo. Subjects continued taking their prestudy chronic, stable nonopioid analgesics, discontinued all intermittent analgesics, and were provided acetaminophen for breakthrough pain. Main Outcome Measures: Time to development of inadequate analgesia; mean daily maximum “pain right now” scores over last 7 days of study drug treatment. Results: The median time to inadequate analgesia was 7 days in placebo versus 21 days in BTDS-treated subjects (P⫽.003). In total, 66% of placebo and 51% of BTDS-treated subjects met the protocol-specified criteria for inadequate analgesia. Mean daily maximum “pain right now” scores were lower in BTDS (3.2⫾0.14) compared with placebo-treated subjects (3.8⫾0.15, P⫽.007). Adverse events reported were those typically observed with other opioids. No clinically important changes in labs, electrocardiograms, or vitals were noted. Conclusions: BTDS had significantly better efficacy than placebo and was generally well tolerated supporting the benefits of BTDS in patients with chronic pain due to OA of the hip and knee. Key Words: Buprenorphine; Chronic pain; Rehabilitation; Transdermal administration.
Poster 155 Effects of Nonsteroidal Anti-Inflammatory Drugs on Histologic Change of the Achilles’ Tendon in Experimental Prolotherapy Model. Kang Sik Lee, Resident; Hyun Jung Kim, Professor; Dong Hwan Yun, Professor; Se Hoon Kim, Professor (Eulji Hospital, Eulji University School of Medicine, Seoul, Republic of Korea), e-mail: [email protected]. Disclosure: None.
Arch Phys Med Rehabil Vol 86, September 2005
Objective: To investigate the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen on histologic change of the Achilles’ tendon of rats for pain control during prolotherapy. Design: Prospective, experimental, randomized controlled study. Setting: Laboratory animal facility. Animals: 60 adult male Sprague-Dawley rats (weight range, 500 –550g). Intervention: The right Achilles’ tendon of rats was injected with 20% dextrose in day 1, day 7, and day 14. Rats were divided into 3 subgroups: celecoxib medication group (10mg䡠kg⫺1䡠d⫺1), acetaminophen medication group (100mg䡠kg⫺1䡠d⫺1), and control group. Medications were given during consecutive 3 days after each injection. Rats were sacrificed at 3 weeks and 6 weeks after first injection of prolotherapy. Gross and histologic evaluation of both Achilles’ tendon were performed. Main Outcome Measures: The transverse diameter of both Achilles’ tendon, the number of fibroblasts on light microscope (⫻400), and the distribution of fibril diameters on electron microscope were assessed. The Wilcoxon signed-rank test and Kruskal-Wallis test was used for statistical analysis, with Pⱕ.05 considered statistically significant. Results: The transverse diameter and the count of fibroblasts of all group increased significantly in the injected tendon compared with the noninjected tendon. However, there were no statistically significant differences among all groups (all P⬎.05). On electron micrograph, the fibrill diameters of injected tendon consisted of mainly smaller sizes with the intermediate sizes. Conclusions: An increase in the transverse diameter and the number of fibroblasts of injected tendon suggests that prolotherapy enhances fibroblastic stimulation and the elaboration of extracellular matrix. This study supports the use of NSAIDs is acceptable for pain relief during prolotherapy if glucose is used for proliperant. Key Words: Prolotherapy; Rehabilitation; Tendon.
Poster 156 Botulinum Toxin Type A Versus Bupivacaine Trigger Point Injections for the Treatment of Myofascial Pain Syndrome: A Randomized Double Blind Crossover Study. Corrie L. Graboski, MD (University of Alberta, Edmonton, AB, Canada); Shaun Gray, MD, PhD; Robert S. Burnham, MD, MSc, e-mail: [email protected]. Disclosure: None. Objective: To compare the effectiveness of trigger point injections using botulinum toxin type A (BTX-A) or bupivacaine in combination with a home-based exercise program in patients with myofascial pain syndrome. Design: Double-blind, crossover trial. Setting: Community physiatry practice. Participants: 18 patients with myofascial pain syndrome recruited by family physician or physiatrist. Intervention: Subjects were randomly assigned to receive initial injections of either 25U of BTX-A per trigger point or bupivacaine injections. A maximum of 8 trigger points were injected per subject. Subjects were followed until their pain returned to 75% of their preinjection pain after which there was a 2 week wash-out period. The subjects then had the same trigger points injected with the other agent. All subjects participated in a home exercise program involving static stretches of the affected muscles. Main Outcome Measures: Magnitude and duration of pain relief, effect on functional ability, satisfaction, and cost savings. Results: Both treatments were effective in reducing pain when compared with baseline (P⬍.05). There was, however, no significant difference between the BTX-A and bupivacaine groups in number of weeks of pain relief, magnitude of pain relief, cost savings, function, or satisfaction. Conclusions: Although both BTX-A and bupivacaine injections were effective, there was no benefit to the use of BTX-A over bupivacaine in the treatment of myofascial pain. In view of the significantly high cost of BTX-A, it is difficult to recommend this agent as a first line intervention in this condition. Key Words: botulinum toxin type A; Rehabilitation; Trigger point.
Poster 157 A New Validated Patient-Completed Neuropathic Pain Screening Tool for Use in the Primary Care Setting. R.K. Portenoy; C. Cleeland; M. Backonja; R. Moskowitz; L. McLeod; T. Griesing (Pfizer Global Pharmaceuticals, Pfizer Inc, New York, NY), e-mail: [email protected]. Disclosure: Portenoy, Consultant for Pfizer Inc; Backonja, Research grant from Pfizer Inc., Consultant for Pfizer Inc.; McLeod, Consultant for Pfizer Inc; Griesing, Pfizer Inc. employee. Objective: To develop and validate a patient-completed screening tool capable of differentiating nociceptive and neuropathic pain in primary care settings. Design: The screening tool was created using data from patients visiting general practitioners (development study) and then validated against data from a 2nd group of chronic pain patients visiting pain specialist offices (validation study). In the development study, patients with nonheadache, chronic pain completed an 89-item chronic-pain questionnaire and were then referred to pain specialists for diagnosis (benchmark). Factor- and univariate-regression analyses combined with input from a panel of experts were used to derive the set of questions comprising the screening tool from the 89 potential items. The tool’s sensitivity and specificity were assessed first against data from the development study and then against data from the validation study. Setting: Multiple clinical research centers in the U.S. Participants: Adults with nonheadache chronic pain ⱖ30 days. Interventions: Not applicable. Main Outcome Measures: Sensitivity, specificity, and concordance of screening tool. Results: In the development study, 586 patients completed the chronic-pain questionnaire. 6 items from the 89-item questionnaire were selected to form the screening tool (scores, ⫺1 to 5). These items identified nearly 70% of neuropathic pain patients as being “likely” or “very likely” to have pain with a neuropathic component, whereas only 25% of nociceptive patients were similarly classified. In the validation study, the tool’s sensitivity, specificity, and concordance were investigated against 308 patients. Experts identified 105, 99, and 104 patients as having neuropathic, nociceptive, and mixed pain. The tool exhibited a .69 concordance index, consistent with findings from the development study. Conclusions: We developed and validated a promising instrument that can aid primary care professionals in estimating the likelihood that a chronic-pain patient may be experiencing neuropathic pain. Key Words: Neuropathic pain; Pain treatment; Primary care; Rehabilitation; Screening tool.