Poster 253: Challenges to Successful Titration of Chronic Low Back Pain Patients to Oxymorphone Extended Release

PM&R

with concordant pain noted at C4/5 and C5/6. The patient subsequently presented 6 days post-procedure with increased neck pain, but was afebrile with a normal white blood cell count. MRI with contrast obtained that same day showed evidence of diskitis at C3/4 and prevertebral abcess. Tissue cultures of the disk and prevertebral tissues were positive for Candida albicans and Staphylococcus aureus. Patient 2 underwent C2/3, C3/4, C4/5, and C5/6 provocation diskography using a right anterolateral approach. The procedure was uncomplicated, with discordant pain noted at C2-3. The patient subsequently presented 9 days post-procedure with severe neck pain. Initial MRI with contrast revealed C1-C4 prevertebral soft tissue edema, but no evidence of diskitis. A follow-up MRI 1 month later revealed evidence of diskitis at C2/3. Biopsy of the C2/3 disk was cultured positive for Klebsiella pneumonia. Setting: Outpatient interventional spine clinic. Results: Patient 1 underwent C3/4 anterior diskectomy and fusion on post-procedure day 10, while Patient 2 was treated conservatively with IV antibiotics. Discussion: Common characteristics found in both patients include long-standing smoking history as well as a history of recent upper respiratory infection treated with antibiotics. The complications reported in these two cases may represent seeding of a disk in the setting of an underlying bacteremia/fungemia. Conclusions: A history of smoking and recent upper respiratory infection may represent risk factors for the development of diskitis following cervical diskography. Additionally, the absence of fever and leukocytosis alone cannot exclude diskitis. Keywords: Diskitis.

Poster 252 Cervical Instability and Medullary Compression in an Achondroplastic Male: A Case Report. Farruq M. Siddiqui, MD (SUNY Downstate Medical Center, Brooklyn, NY, NY); Sanjeev Agarwal, MD; Shamel Hashish, MD; Seung J. Park, MD. Disclosures: F. M. Siddiqui, None. Setting: Tertiary care teaching hospital. Patient: A 24-year-old achondroplastic dwarf with neck pain along with pain and weakness on left side of the body. Case Description: Patient was evaluated for intermittent neck pain radiating down to left side of the body, left-sided weakness which gradually progressed over a period of 6 years. The severity of symptoms made the patient almost non-ambulatory until he started using a cane for support. MRI and CT scan imaging of the cervical spine demonstrated instability at the level of C1-C2 with evidence of subluxation and an os odontoideum. Results: Operative treatment with cervico-occipital fusion, along with foramen magnum decompression was performed resulting in immediate relief of pain postoperatively. With rehabilitation, patient recovered muscle strength, and prior

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to discharge, he was free of symptoms and could ambulate independently using a pediatric walker. Discussion: There is a spectrum of neurologic manifestations in pediatric patients with achondroplasia, such as cervicomedullary compressive syndromes, syringomyelia, hydrocephalus etc, which is not common in adults. Adults do not usually experience significant neurologic complications except for spinal stenosis involving L1-L4. This is an adult case of achondroplasia with a rare neurologic manifestation of cervical instability causing subluxation and compressive symptoms. The finding of os odontoideum is a malformation of the craniovertebral junction with a hypoplastic dens which is separated from the body of the axis leading to impingement of the upper cervical cord. Conclusions: Although vertebral deformity is a common complication, cervical instability along with medullary compression is a rare finding in adult achondroplasia. Excellent results may be anticipated by decompressive surgical procedures in a timely fashion with reversal of neurological deficit. Keywords: Achondroplasia, Foramen magnum, Rehabilitation.

Poster 253 Challenges to Successful Titration of Chronic Low Back Pain Patients to Oxymorphone Extended Release. John H. Peniston, DO (Feasterville Family Health Care Center, Feasterville, PA); Errol Gould, PhD. Disclosures: J. H. Peniston, None. Objective: Evaluate the effectiveness of a program of gradual titration with oxymorphone extended release (ER) in patients with chronic lower back pain (CLBP). Design: Subgroup analysis of 2 randomized placebo-controlled trials. Setting: Multidisciplinary pain centers. Participants: Adults with moderate to severe CLBP. Interventions: Opioid-experienced and opioid-naive patients discontinued their previous pain regimen and were titrated for ⱕ1 month to an oxymorphone ER dose that reduced pain to ⱕ40 mm on a 100-mm Visual Analog Scale. Opioid-experienced patients were limited to ⱕ2 daily doses of 5 mg oxymorphone immediate release as rescue medication. Main Outcome Measures: Patient disposition in subgroups stratified according to age, sex, and prior opioid experience. Results: Of 575 enrolled patients, 80 (13.9%) were seniors (aged ⱖ65 y), 297 (51.7%) were women, and 250 (43.5%) were opioid-experienced. Of opioid-experienced patients, most received hydrocodone (n ⫽ 104) or oxycodone (n ⫽ 79) as their previous opioid. Overall, 348 patients (60.5%) successfully completed titration. Patients aged ⬍65 years were more likely than seniors to complete titration (63.0% vs 45.0%; P ⫽ .002), largely because of a higher rate of discontinuations due to adverse events in seniors (40.0% vs 14.8%;

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P ⬍ .001). Titration was successful in similar percentages of men and women (62.6% vs 58.6%; P ⫽ .33) and of opioidnaive and opioid-experienced patients (63.1% vs 57.2%; P ⫽ .15). However, in the opioid-experienced subgroup, patients who received oxycodone previously were significantly less likely to complete titration than those who had received hydrocodone (45.6% vs 61.5%; P ⫽ .03). Conclusions: The majority of patients with moderate to severe CLBP were successfully titrated to a twice-daily oxymorphone ER dose that provided effective, generally welltolerated analgesia. Seniors and patients switching from oxycodone may require more careful titration to optimize success. Keywords: Rehabilitation, Oxymorphone, Low-back pain, Opioids.

Poster 254 Cognitive Interviewing and Interventions in Chronic Pain Rehabilitation: A Case Report. Leonard Kamen, DO (MossRehab, Philadelphia, PA). Disclosures: L. Kamen, Allergan, Speakers bureau; Eli Lilly, Speakers bureau; King, Speakers bureau; Accorda, Speakers bureau. Patients or Programs: Cognitive based interviewing technique (CIT), an enhanced method of communication used to obtain respondent feedback, integrates interviewing skills used during pain management (PM) and addiction treatment. Techniques from addiction medicine, including “motivational interviewing” (MI) “and ”reflective listening“ (RL), and pain medicine, including cognitive behavioral techniques (CBT), establishes a patient-participatory, goaloriented, self-empowering PM process. Incorporating CIT ameliorates challenges to PM including fear-avoidance behavior and medication noncompliance subsequently benefiting the patient and practitioner. Program Description: Skills in MI and RL are utilized extensively in addiction medicine. Cognitive behavioral therapies are well established tools in rehabilitation of chronic pain syndromes. Cognitive interviewing skills with restructuring and reframing techniques are employed during initial and subsequent follow up patient interviews. Integration of goal-oriented physical, medical, and psychological therapeutics is utilized where indicated to reinforce an educational agenda critical to engagement of the pain patient in this self-empowering dynamic. Patient-oriented workbooks outlining CBT and acceptance are reviewed during follow-up evaluations to encourage and reinforce CIT during this mentoring process. Setting: Outpatient non-interventional physical medicine and rehabilitation clinic. Results: Outcomes in an outpatient population of chronic pain patients have been globally positive utilizing this set of interview techniques. Reduction in abuse of opioids and improved compliance with medication, psychological techniques, and physical exercise regimens are noted.

POSTER PRESENTATIONS

Conclusions: Knowledge and exposure to these non-traditional CIT skills has demonstrated benefit to patients, families and practitioners in the practice of chronic pain management rehabilitation. Developing protocols for teaching this skill set to residents will provide an economy of time and efficiency in biopsychosocial treatment of chronic pain. Keywords: Rehabilitation, Pain, Cognitive.

Poster 255 Comparison of Treatment Outcomes in Patients not on Opioids and those Weaned from Opioids During a Functional Restoration Program: A Case Series. Maury R. Ellenberg, MD (Sinai Grace Hospital Functional Recovery Program, Wayne State University, Oak Park, MI); Brenda L. Blind, MA; Jay L. Cohen, PhD; Maury R. Ellenberg, MD; Maryjo R. Gavin, PhD; Jonathan D. Tait, DO. Disclosures: M. Ellenberg, None. Objective: To determine whether opioid use at admission effects outcomes in a population of chronic pain patients who completed an interdisciplinary functional restoration program. Design: Retrospective chart review. Setting: University hospital outpatient functional restoration program (FRP). Participants: 62 patients who completed the program in 2007. Interventions: Seven week, interdisciplinary FRP coupled with opioid wean by program completion. Main Outcome Measures: Self-reported: Numeric Rating Scale (NRS), Oswestry Disability Questionnaire, Global Severity Index (GSI) of the Symptoms Check List-90 Revised (SCL-90R). Functional Measures: 65-foot dash, Treadmill Time, Floor to Waist Box Squat. Results: All patients completing the program demonstrated significant improvements on all outcome measures (P⬍.001). For the opioid and non-opioid groups, the mean change and standard deviation for the NRS were 1.32 ⫾ 2.06 and 1.34 ⫾ 2.23, respectively; Oswestry 28% ⫾ 0.3% and 33% ⫾ 0.2%, respectively. and the GSI 6% ⫾ 0.1% and 8% ⫾ 0.1%, respectively. Interestingly, the average NRS at admission was 6.30 for the opioid group and 4.91 for the non-opioid group. The average percentage change and standard deviations for the opioid and non-opioid groups on the 65-foot dash were 32% ⫾ 0.2% and 29% ⫾ 0.2% respectively; treadmill time 160% ⫾ 130% and 129% ⫾ 2%, respectively, and floor to waist box squat 259% ⫾ 2% and 289% ⫾ 2%, respectively. Overall, no significant differences were found in the outcomes for those enrolled on opioids and subsequently weaned, and for those not on opioids at the time of enrollment. Conclusions: Patients weaned from opioids were able to achieve significant improvements in self-reported and functional measures through completion of a functional restora-