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Poster 500 Transcutaneous Pulsed Radiofrequency for Treating CRPS Related Foot and Ankle Pain: A Case Report
S360
Participants: 4695 subjects aged 20-64 selected at random from specific geographical locations across the US and each individual subject was assigned a weight to most accurately represent the US population. Interventions: None Main Outcome Measures: Survey Weighted proportions to determine the percentage of those with subacute (>6 weeks) and chronic (>3 months) LBP. Regression model to determine association of chronic LBP with gender, age, education and ethnicity. Results or Clinical Course: The mean age was 41.8 years. 13% of respondents had subacute or chronic back pain at some point in their life. 70% of those (9% overall) have had chronic low back pain. 83% of those (7.5% overall) who ever had chronic back pain had back pain at the time of the survey. Greater age (p<0.001), Lower education level (p<0.001), and white ethnicity (p<0.001) were statistically significantly associated with higher rates of chronic low back pain. Gender was not statistically significantly associated (p¼.32). Conclusions: These estimates are similar to those found by other epidemiologic studies. However, our findings differ in that female gender is not significantly associated with chronic low back pain, while white ethnicity is. The large proportion of those with subacute LBP who develop chronic LBP combined with the large proportion of those with chronic LBP who have current pain attest to the importance of early intervention. Poster 498 Prevalence and Efficacy of First Line Treatments for Chronic Low Back Pain. Imran J. Siddiqui, MD (Spaulding Rehbailitation Hospital, Charlestown, MA, United States); Paul Gerrard, MD. Disclosures: I. J. Siddiqui, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: Little is known about the responsiveness of chronic low back pain (LBP) to various first line treatment options such as non-steroidal anti inflammatories (NSAIDs) and exercise. Our objective is to determine which are most commonly used for treatment and their respective effectiveness. Design: Cross-sectional design using the National Health and Nutrition Examination Survey 2010 (NHANES) data collected by the Centers for Disease Control (CDC). Setting: Telephone survey. Participants: 626 subjects of working age (20-64) with chronic low back pain were sub-sampled from a nationwide sample of 4695 subjects from specific geographical locations across the US to accurately represent the US population. Interventions: None Main Outcome Measures: Survey weighted proportions to determine the percentage of individuals with chronic low back pain that used ibuprofen, naproxen, aspirin, cox-2 inhibitors, and exercise to improve their chronic LBP and to determine their effectiveness on a 4 point scale. Results or Clinical Course: The mean age was 44.1 years. 66.9% of subjects had chronic LBP that never remits and 83.3% had pain at the time of the survey. Of those with chronic LBP, 81.1% tried ibuprofen, 54.9% tried naproxen, 33.8% tried aspirin, and 19.8% tried cox-2 inhibitors. 63.9% reported at least some improvement of pain with ibuprofen, 40.1% with naproxen, 66.3%
PRESENTATIONS
with cox-2 inhibitors, and 24.9% with aspirin. 66.9% of subjects with chronic LBP reported significant improvement in pain with exercise. Conclusions: The vast majority of chronic LBP is non-remitting. Ibuprofen is the most prescribed first line medication for chronic LBP. Exercise has good benefit in pain reduction in chronic LBP. Ibuprofen and cox-2 inhibitors are more effective than naproxen and aspirin in relieving chronic LBP; however their effectiveness in no greater than exercise. Poster 499 Validity of Objective Assessment Questionnaire in Chronic Neck and Chronic Low Back Pain Patients Using Opioid Medications. Aashish Deshpande, MD (WSUPMR Oakwood, Novi, MI, United States); Natasha Smith, MS, PA-C, MHSA. Disclosures: A. Deshpande, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To assess the validity of an Objective Assessment Questionnaire in a population of Chronic Pain patients prescribed Opioid medications within a physiatric practice. Design: Pilot study, 18 consecutive patients with chronic low back pain or chronic neck pain diagnoses, prescribed opioid medication, were asked to fill out a 9 point questionnaire indicating their experiences for 30 days prior to opioid medication use and then for a 30 day timeframe with opioid medication use. The questions included number of ER visits, Hospital admits, missed work days, pain flares, skipped meals, days of use of alcohol or marijuana for pain control, days limited to couch/chair/bed, activity days limited, ADL days completed. Setting: Physiatric outpatient clinic, associated with an academic teaching program. Participants: 18 consecutive patients who fulfilled diagnostic and treatment criteria and agreed to participate in study. Interventions: Patients filled out a questionnaire. Main Outcome Measures: Difference between reported scores in each patient before and after opioid medication use. Ttest, one tailed paired was used for analysis. Results or Clinical Course: 8 out of 9 questions showed statistically significant differences in responses to timeframes before and after opioid treatment. T-test values ER Visits 0.007, Hospital Admits 0.03, Missed work days 0.02, Pain Flares 8.97x10-10, Skipped Meals 0.007, Couch/Chair/Bed Days 0.0003, activity days limited 0.006, ADL days completed 6.11x10-6 Conclusions: The Objective Assessment Questionnaire is a simple, short, and valid measure of the effectiveness of opioid medication treatment in chronic pain management, providing evidence of functional improvements and allowing clinicians to further strengthen their documentation in this patient population. Poster 500 Transcutaneous Pulsed Radiofrequency for Treating CRPS Related Foot and Ankle Pain: A Case Report. Ravi Mirpuri, DO (University of California Irvine, Orange, CA, United States); Patricia W. Nance, MD. Disclosures: R. Mirpuri, No Disclosures: I Have No Relevant Financial Relationships to Disclose.
PM&R
Case Description: A 37-year-old man presented with chronic CRPS pain manifestations in his right foot and ankle for 10 years after having multiple orthopedic surgeries and history of neuroma excision. Physical examination of foot demonstrated hyperalgesia, edema, warmth, and shiny skin appearance. NSAIDS, gabapentin, TENS unit, epidural injections, and local lidocaine block were tried in the past but offered minimal relief. His Initial VAS pain score on presentation was a 7/10. Additionally he had functional limitations of having to drive with his left foot, difficulty with prolonged standing greater than 2 minutes, and inability to run or dance. A 30 minute trial of pulsed radiofrequency (PRF) was given with applicator placed directly underneath his R ankle. Settings were regulated at a frequency of 27.12 MHz, 42 microsecond pulse width, and 1000 pulses per second. After the trial patient was then issued a portable PRF generator for home usage. He was instructed to repeat the same treatment twice daily and follow up in clinic at 1 and 2 months. Program Description: N/A Setting: Outpatient Rehabilitation Clinic. Results or Clinical Course: During the initial trial patient had immediate pain relief to a VAS pain score of 4/10. After 1 month follow up his pain was reduced further to a 3/10. At 2 months his pain continued to reduce with a self-reported daily pain score that ranged from 0-3/10. Additionally patient reported functional improvement of being able to walk 2-3 blocks without pain limitations. Also he was able to drive with his R foot again after receiving PRF. Discussion: This is the first reported case, to our knowledge, of transcutaneous PRF successfully being utilized to treat CRPS related pain. This should not be confused with the multiple case reports of percutaneous PRF being used for sympathetic neurolysis which is entirely different. Transcutaneous PRF is a non-invasive approach that does not involve traumatic penetration of the skin nor direct nerve trauma. In this case it provided significant analgesia and functional improvement after multiple alternative treatment modalities failed. Conclusions: Transcutaneous pulsed radiofrequency may have a role in treating CRPS related pain. Further research should be considered on investigating the potential benefits of PRF analgesia for individuals seeking non-invasive treatment options for CRPS. Poster 501 Painful Legs Moving Toes with Novel Vasomotor and Leg Movement Symptoms: A Case Report. Alexander Lloyd (Icahn School of Medicine at Mount Sinai, New York, NY, United States); Yinfei Xu, MD; Parag Sheth, MD. Disclosures: A. Lloyd, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 69-year-old woman presented with bilateral, sharp, burning leg pain of several years, worse on the right and accompanied by involuntary flexion/extension of all digits. Symptoms progressed to include muscle spasms and leg jerking, increased pain intensity, and bilateral distribution. She also reported segmental, bilateral color and temperature changes in her right leg. Walking, cold, pressure, ankle movement, and Valsalva exacerbated the pain. Heat and relieving pressure on the feet provided mild relief. Trauma history included a car accident at 31
Vol. 6, Iss. 9S, 2014
S361
(full recovery with rehabilitation), recurrent ankle instability, plantar fasciitis, and an unverified history of feet neuromas. Of note, her sister’s terminal illness and need for significant care coincided with symptom onset. Setting: Tertiary care rehabilitation clinic. Results or Clinical Course: Therapy included trials of amitryptiline, nortryptiline (some relief but unacceptable behavior change), gabapentin, pramipexole, celecoxib, diazepam (temporary relief), oxycodone, and lidocaine patches. Caudal epidural and physical therapy provided no relief and electroacupuncture worsened her pain. Spine MRI showed stable posterior broad based disc bulge at L4-5 with annular fissure. MRI of the foot could not be read due to movement. The patient refused EMG. Lab results showed MGUS. Patient was to follow up with pain management and a sleep study. Discussion: This patient’s rare presentation is typical of PLMT, but her leg jerking, vasomotor dysreglation, and possible pedal neuromas have not been reported in the PLMT literature. They emphasize the significant overlap between descriptions of PLMT and complex regional pain syndrome (CRPS), which is characterized by chronic pain and separated from PLMT by a combination of sensory/vasomotor/sudomotor/motor symptoms. Because of their expertise in rehabilitation, musculoskeletal disease and pain management, physiatrists are likely to see these rare patients and may be positioned to offer treatment once more is known about PLMT. Conclusions: PLMT is debilitating disease potentially encountered by physiatrists and our report helps guide their understanding and care. Their unique perspective is underrepresented in the literature and important as understanding of this disease progresses. Poster 502 Epidural Hematoma and Paraplegia after Spinal Cord Stimulator Trial Lead Removal: A Case Report. Peter Navarro (University of Miami, Miami, FL, United States); Jose Mena, MD. Disclosures: P. Navarro, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 63-year-old woman with a history notable for thoracic myelopathy and T7-T8 discectomy who presented to the interventional pain clinic with complaints of burning pain of the ribs and anterior chest. She had already failed conservative measures such as intercostal block, physical therapy and medications by this point, so it was felt she would be a great candidate for a spinal cord stimulator trial. She was given precautions before the trial to prevent lead migration and stop any anticoagulants to prevent any risk of bleeding following the American Society of Regional Anesthesia guidelines. She had a successful 7-day spinal cord stimulator trial with 80% improvement in her pain. After ensuring she had not been taking any potential blood thinners, the spinal cord stimulator lead was removed. The catheter tip was intact and there was no evidence of bleeding; the patient had no immediate complications. Four hours after lead removal she began experiencing lower extremity paraplegia. She presented to an emergency room and a thoracic MRI revealed an epidural hematoma. On examination her lower extremity motor strength was 1/5 bilaterally and also lost control of her bladder function.
Participants: 4695 subjects aged 20-64 selected at random from specific geographical locations across the US and each individual subject was assigned a weight to most accurately represent the US population. Interventions: None Main Outcome Measures: Survey Weighted proportions to determine the percentage of those with subacute (>6 weeks) and chronic (>3 months) LBP. Regression model to determine association of chronic LBP with gender, age, education and ethnicity. Results or Clinical Course: The mean age was 41.8 years. 13% of respondents had subacute or chronic back pain at some point in their life. 70% of those (9% overall) have had chronic low back pain. 83% of those (7.5% overall) who ever had chronic back pain had back pain at the time of the survey. Greater age (p<0.001), Lower education level (p<0.001), and white ethnicity (p<0.001) were statistically significantly associated with higher rates of chronic low back pain. Gender was not statistically significantly associated (p¼.32). Conclusions: These estimates are similar to those found by other epidemiologic studies. However, our findings differ in that female gender is not significantly associated with chronic low back pain, while white ethnicity is. The large proportion of those with subacute LBP who develop chronic LBP combined with the large proportion of those with chronic LBP who have current pain attest to the importance of early intervention. Poster 498 Prevalence and Efficacy of First Line Treatments for Chronic Low Back Pain. Imran J. Siddiqui, MD (Spaulding Rehbailitation Hospital, Charlestown, MA, United States); Paul Gerrard, MD. Disclosures: I. J. Siddiqui, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: Little is known about the responsiveness of chronic low back pain (LBP) to various first line treatment options such as non-steroidal anti inflammatories (NSAIDs) and exercise. Our objective is to determine which are most commonly used for treatment and their respective effectiveness. Design: Cross-sectional design using the National Health and Nutrition Examination Survey 2010 (NHANES) data collected by the Centers for Disease Control (CDC). Setting: Telephone survey. Participants: 626 subjects of working age (20-64) with chronic low back pain were sub-sampled from a nationwide sample of 4695 subjects from specific geographical locations across the US to accurately represent the US population. Interventions: None Main Outcome Measures: Survey weighted proportions to determine the percentage of individuals with chronic low back pain that used ibuprofen, naproxen, aspirin, cox-2 inhibitors, and exercise to improve their chronic LBP and to determine their effectiveness on a 4 point scale. Results or Clinical Course: The mean age was 44.1 years. 66.9% of subjects had chronic LBP that never remits and 83.3% had pain at the time of the survey. Of those with chronic LBP, 81.1% tried ibuprofen, 54.9% tried naproxen, 33.8% tried aspirin, and 19.8% tried cox-2 inhibitors. 63.9% reported at least some improvement of pain with ibuprofen, 40.1% with naproxen, 66.3%
PRESENTATIONS
with cox-2 inhibitors, and 24.9% with aspirin. 66.9% of subjects with chronic LBP reported significant improvement in pain with exercise. Conclusions: The vast majority of chronic LBP is non-remitting. Ibuprofen is the most prescribed first line medication for chronic LBP. Exercise has good benefit in pain reduction in chronic LBP. Ibuprofen and cox-2 inhibitors are more effective than naproxen and aspirin in relieving chronic LBP; however their effectiveness in no greater than exercise. Poster 499 Validity of Objective Assessment Questionnaire in Chronic Neck and Chronic Low Back Pain Patients Using Opioid Medications. Aashish Deshpande, MD (WSUPMR Oakwood, Novi, MI, United States); Natasha Smith, MS, PA-C, MHSA. Disclosures: A. Deshpande, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To assess the validity of an Objective Assessment Questionnaire in a population of Chronic Pain patients prescribed Opioid medications within a physiatric practice. Design: Pilot study, 18 consecutive patients with chronic low back pain or chronic neck pain diagnoses, prescribed opioid medication, were asked to fill out a 9 point questionnaire indicating their experiences for 30 days prior to opioid medication use and then for a 30 day timeframe with opioid medication use. The questions included number of ER visits, Hospital admits, missed work days, pain flares, skipped meals, days of use of alcohol or marijuana for pain control, days limited to couch/chair/bed, activity days limited, ADL days completed. Setting: Physiatric outpatient clinic, associated with an academic teaching program. Participants: 18 consecutive patients who fulfilled diagnostic and treatment criteria and agreed to participate in study. Interventions: Patients filled out a questionnaire. Main Outcome Measures: Difference between reported scores in each patient before and after opioid medication use. Ttest, one tailed paired was used for analysis. Results or Clinical Course: 8 out of 9 questions showed statistically significant differences in responses to timeframes before and after opioid treatment. T-test values ER Visits 0.007, Hospital Admits 0.03, Missed work days 0.02, Pain Flares 8.97x10-10, Skipped Meals 0.007, Couch/Chair/Bed Days 0.0003, activity days limited 0.006, ADL days completed 6.11x10-6 Conclusions: The Objective Assessment Questionnaire is a simple, short, and valid measure of the effectiveness of opioid medication treatment in chronic pain management, providing evidence of functional improvements and allowing clinicians to further strengthen their documentation in this patient population. Poster 500 Transcutaneous Pulsed Radiofrequency for Treating CRPS Related Foot and Ankle Pain: A Case Report. Ravi Mirpuri, DO (University of California Irvine, Orange, CA, United States); Patricia W. Nance, MD. Disclosures: R. Mirpuri, No Disclosures: I Have No Relevant Financial Relationships to Disclose.
PM&R
Case Description: A 37-year-old man presented with chronic CRPS pain manifestations in his right foot and ankle for 10 years after having multiple orthopedic surgeries and history of neuroma excision. Physical examination of foot demonstrated hyperalgesia, edema, warmth, and shiny skin appearance. NSAIDS, gabapentin, TENS unit, epidural injections, and local lidocaine block were tried in the past but offered minimal relief. His Initial VAS pain score on presentation was a 7/10. Additionally he had functional limitations of having to drive with his left foot, difficulty with prolonged standing greater than 2 minutes, and inability to run or dance. A 30 minute trial of pulsed radiofrequency (PRF) was given with applicator placed directly underneath his R ankle. Settings were regulated at a frequency of 27.12 MHz, 42 microsecond pulse width, and 1000 pulses per second. After the trial patient was then issued a portable PRF generator for home usage. He was instructed to repeat the same treatment twice daily and follow up in clinic at 1 and 2 months. Program Description: N/A Setting: Outpatient Rehabilitation Clinic. Results or Clinical Course: During the initial trial patient had immediate pain relief to a VAS pain score of 4/10. After 1 month follow up his pain was reduced further to a 3/10. At 2 months his pain continued to reduce with a self-reported daily pain score that ranged from 0-3/10. Additionally patient reported functional improvement of being able to walk 2-3 blocks without pain limitations. Also he was able to drive with his R foot again after receiving PRF. Discussion: This is the first reported case, to our knowledge, of transcutaneous PRF successfully being utilized to treat CRPS related pain. This should not be confused with the multiple case reports of percutaneous PRF being used for sympathetic neurolysis which is entirely different. Transcutaneous PRF is a non-invasive approach that does not involve traumatic penetration of the skin nor direct nerve trauma. In this case it provided significant analgesia and functional improvement after multiple alternative treatment modalities failed. Conclusions: Transcutaneous pulsed radiofrequency may have a role in treating CRPS related pain. Further research should be considered on investigating the potential benefits of PRF analgesia for individuals seeking non-invasive treatment options for CRPS. Poster 501 Painful Legs Moving Toes with Novel Vasomotor and Leg Movement Symptoms: A Case Report. Alexander Lloyd (Icahn School of Medicine at Mount Sinai, New York, NY, United States); Yinfei Xu, MD; Parag Sheth, MD. Disclosures: A. Lloyd, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 69-year-old woman presented with bilateral, sharp, burning leg pain of several years, worse on the right and accompanied by involuntary flexion/extension of all digits. Symptoms progressed to include muscle spasms and leg jerking, increased pain intensity, and bilateral distribution. She also reported segmental, bilateral color and temperature changes in her right leg. Walking, cold, pressure, ankle movement, and Valsalva exacerbated the pain. Heat and relieving pressure on the feet provided mild relief. Trauma history included a car accident at 31
Vol. 6, Iss. 9S, 2014
S361
(full recovery with rehabilitation), recurrent ankle instability, plantar fasciitis, and an unverified history of feet neuromas. Of note, her sister’s terminal illness and need for significant care coincided with symptom onset. Setting: Tertiary care rehabilitation clinic. Results or Clinical Course: Therapy included trials of amitryptiline, nortryptiline (some relief but unacceptable behavior change), gabapentin, pramipexole, celecoxib, diazepam (temporary relief), oxycodone, and lidocaine patches. Caudal epidural and physical therapy provided no relief and electroacupuncture worsened her pain. Spine MRI showed stable posterior broad based disc bulge at L4-5 with annular fissure. MRI of the foot could not be read due to movement. The patient refused EMG. Lab results showed MGUS. Patient was to follow up with pain management and a sleep study. Discussion: This patient’s rare presentation is typical of PLMT, but her leg jerking, vasomotor dysreglation, and possible pedal neuromas have not been reported in the PLMT literature. They emphasize the significant overlap between descriptions of PLMT and complex regional pain syndrome (CRPS), which is characterized by chronic pain and separated from PLMT by a combination of sensory/vasomotor/sudomotor/motor symptoms. Because of their expertise in rehabilitation, musculoskeletal disease and pain management, physiatrists are likely to see these rare patients and may be positioned to offer treatment once more is known about PLMT. Conclusions: PLMT is debilitating disease potentially encountered by physiatrists and our report helps guide their understanding and care. Their unique perspective is underrepresented in the literature and important as understanding of this disease progresses. Poster 502 Epidural Hematoma and Paraplegia after Spinal Cord Stimulator Trial Lead Removal: A Case Report. Peter Navarro (University of Miami, Miami, FL, United States); Jose Mena, MD. Disclosures: P. Navarro, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 63-year-old woman with a history notable for thoracic myelopathy and T7-T8 discectomy who presented to the interventional pain clinic with complaints of burning pain of the ribs and anterior chest. She had already failed conservative measures such as intercostal block, physical therapy and medications by this point, so it was felt she would be a great candidate for a spinal cord stimulator trial. She was given precautions before the trial to prevent lead migration and stop any anticoagulants to prevent any risk of bleeding following the American Society of Regional Anesthesia guidelines. She had a successful 7-day spinal cord stimulator trial with 80% improvement in her pain. After ensuring she had not been taking any potential blood thinners, the spinal cord stimulator lead was removed. The catheter tip was intact and there was no evidence of bleeding; the patient had no immediate complications. Four hours after lead removal she began experiencing lower extremity paraplegia. She presented to an emergency room and a thoracic MRI revealed an epidural hematoma. On examination her lower extremity motor strength was 1/5 bilaterally and also lost control of her bladder function.