PM&R - Articles in Press

Adverse Events Associated With Fluoroscopically Guided Sacroiliac Joint Injections - Corrected Proof

2012-04-30

Objective: To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ). Design: A retrospective cohort study. Setting: Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. Participants: English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007. Interventions: After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests. Main Outcome Measures: The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events. Results: A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024). Conclusions: Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events.

The Effects of Concussion Legislation One Year Later—What Have We Learned: A Descriptive Pilot Survey of Youth Soccer Player Associates - Corrected Proof

2012-04-30

Objective: To assess the knowledge of youth soccer athletes' parents, coaches, and soccer officials regarding concussion and return-to-play guidelines contained in the Lystedt Law in Washington State. Design: Survey study. Setting: Surveys were distributed via the youth soccer association monthly electronic newsletter in September and October 2010. Links to the survey also were provided via the Washington Youth Soccer Facebook page and Twitter feed. Participants: Respondents were 18 years or older and were associated with Washington Youth Soccer. Main Outcome Measures: The percentage of correct responses to questions regarding the identification and management of concussion symptoms and return to play guidelines as outlined in the Lystedt Law. Results: A total of 391 adults responded; 63% were exclusively parents, 20% were coaches, and 17% were noncoaches (eg, club officers, referees, or volunteers). A total of 96% knew that concussions were a type of traumatic brain injury, 93% identified concussions as serious, and 93% knew that loss of consciousness is not universal. From the responses, 98% identified neurological manifestations of concussions, 90% chose to delay return to play in the presence of neurological symptoms, 85% were aware of the Lystedt Law, and only 73% knew that players must receive written clearance to return to play. A total of 88% were aware that a parent or legal guardian was not allowed to clear an athlete to return to play if a trained professional was not available. Survey respondents were less sure of soccer association guidelines for reporting medical clearance to club officials. Conclusions: These data suggest that, although general knowledge of parents, coaches, and referees in youth soccer in Washington State is high, gaps in knowledge and practice regarding the prevention of concussion in youth soccer athletes still exist.

Reliability and Repeatability of the Hoffmann Sign - Corrected Proof

2012-04-30

Objective: To determine the inter-rater, intrarater, and intrasubject reliability of the Hoffmann sign. Design: Observational, cross-sectional study. Setting: Veterans Affairs medical center. Patients: Fifty-two consenting subjects without amputation of the first through third fingers, fixed finger contractures, relapsing remitting multiple sclerosis, or any acute central neurological illness or injury within the past 3 months requiring hospital admission were recruited from inpatients and outpatients in the Spinal Cord Injury and Physical Medicine and Rehabilitation services. Interventions: The Hoffmann sign was elicited by 1 primary and 3 secondary investigators who used a standardized technique. The Hoffmann sign was considered positive if any reflexive flexion of the distal phalanx of the thumb or any of the fingers was present. In the first session, the primary and one secondary examiner performed 2 trials on both hands of each subject. Each investigator pair repeated the procedure in a second session. Main Outcome Measures: Cohen's κ coefficient was calculated to determine (1) inter-rater reliability, calculated per investigator pair per hand, for the first trial of a session; (2) intrarater reliability, calculated between the 2 trials of each session per investigator; and (3) intrasubject reliability, calculated per hand of each subject between the first trials of the 2 sessions. Results: Inter-rater κ was 0.65 (188 pairs), intrarater κ was 0.89 (384 pairs), and intrasubject κ was 0.73 (178 pairs). All κ values were obtained with P < .01. Conclusions: The Hoffmann sign has substantial inter-rater and intrasubject reliability, in addition to outstanding intrarater reliability, when tested with the use of a standardized technique.

Disparities in Activity Level and Nutrition Between Patients With Chronic Hepatitis C and Blood Donors - Corrected Proof

2012-04-30

Objective: To compare physical activity levels and dietary choices of patients who have chronic hepatitis C (CHC) with those of blood donors (BDs). Design: A prospective survey. Setting: A liver disease treatment center and a blood donor center from a nonprofit health system. Patients: A total of 149 subjects (93 with CHC and 56 BDs) participated. Subjects were 18 years or older and agreed to participate; those with CHC had no evidence of cirrhosis. Methods: All subjects provided basic clinical information and completed a nutrition survey, which contained questions about dietary choices and their frequency, and the Human Activity Profile, which measured maximum effort (Maximum Activity Score; MAS) and daily activity (Adjusted Activity Score; AAS). Independent samples t-tests, Pearson correlations, and multiple stepwise regression analyses were performed. Main Outcomes Measurements: MAS and AAS scales and 13 indices on the nutrition survey. Results: No significant differences were found between BDs and patients with CHC in terms of age, gender, race, body mass index, hyperlipidemia, hypertension, or diabetes mellitus. Mean body mass index was 27.5, 17.8% had hyperlipidemia, and 9.6% had diabetes. BDs reported significantly more exercise per week (mean: patients with CHC = 193.6 minutes/week and BDs = 280.4 minutes/week; P = .039) and had a significantly greater MAS (mean: patients with CHC = 77.2 and BDs = 87.4, P = .0001) and AAS (mean: patients with CHC = 72.58 and BDs = 83.8, P = .0001). Stepwise multiple regression analysis proposed 2 models predicting AAS: the presence of CHC (R = .445; R2 = .198; adjusted R2 = .184); and the presence of CHC and presence of hypertension (R = .537; R2 = .289; adjusted R2 = .263). BDs consumed significantly more alcohol and starchy foods than did patients with CHC (P = .0001 and P = .031, respectively), which may be explained by the compliance of patients with CHC to their hepatologist's recommendations regarding the minimization of alcohol consumption. Conclusions: Persons with CHC participate in less activity and less vigorous physical activity than do BDs and consume less starch and alcohol. These data about activity level and dietary intake in patients with CHC are novel; few data on these topics have been published previously. Low level of activity adds a substantial risk to this overweight CHC population, many of whom have multiple components of metabolic syndrome.

Exceptional Neurologic Recovery in a Teenage Football Player After Second Impact Syndrome With a Thin Subdural Hematoma - Corrected Proof

2012-04-20

Second impact syndrome (SIS) occurs when a person sustains a second brain injury before the symptoms of an initial brain injury resolve . Severe brain edema develops due to cerebral vasculature dysautoregulation and causes significant neurologic deficits . SIS is a rare condition that occurs primarily in adolescents and young adults. Severe neurologic deficits and death typically occur with SIS . This report describes an exceptional neurologic recovery in a teenage football player after SIS with a thin subdural hematoma (SDH). Institutional review board approval was obtained for this case study.

Fear Avoidance Beliefs Predict Disability in Older Adults With Chronic Low Back Pain - Corrected Proof

Alejandra Camacho-Soto, Gwendolyn A. Sowa, Subashan Perera, Debra K. Weiner — 2012-04-20

Objectives: To determine whether fear avoidance beliefs (FABs) in older adults with chronic low back pain (CLBP) are significantly associated with gait speed and/or self-report (Roland Morris Questionnaire). Design: Cross-sectional analysis. Setting: An academic medical center (single site). Participants: Two hundred English-speaking participants aged 65 years and older with CLBP every day or almost every day of moderate or greater intensity for ≥3 months. Main Outcome Measurements: The physical activity portion of the FAB questionnaire assessed FABs. Disability was measured with gait speed and the Roland Morris Questionnaire. Covariates measured included age, gender, body mass index, chronic disease (Cumulative Illness Rating Scale), depression (Geriatric Depression Scale), and pain (McGill Pain Questionnaire Short Form). Results: FABs were significantly associated with the Roland Morris Questionnaire (P < .0001) and gait speed (P = .002) after controlling for all covariates. Conclusion: FABs related to physical activity in older adults with CLBP were significantly associated with both self-reported and performance-based disability after controlling for known confounders. Previous studies have reported similar associations between self-reported measures of disabling back pain and FABs. Ours is the first study to examine the relationship between FAB and gait speed, a powerful predictor of morbidity and mortality. Future work should examine whether targeting fear avoidance in addition to other psychosocial measures in older adults with CLBP improves gait speed and functional independence.

Sonographic Evaluation of Supraspinatus Cross-sectional Area in Collegiate Baseball Players - Corrected Proof

2012-04-20

Objective: To establish the normal thickness of the supraspinatus tendon in collegiate baseball players with the use of ultrasound and to determine whether there are any significant differences between the dominant and nondominant supraspinatus thickness. Design: A cross-sectional observational study. Setting: An outpatient clinical setting. Participants: Twelve healthy, asymptomatic collegiate pitchers between the ages of 19 and 22 years. Methods: Sonographic evaluation of 12 asymptomatic pitchers (9 right-hand dominant and 3 left-hand dominant) between the ages of 19 and 22 years was performed in a transverse plane (short axis) and longitudinal view (long axis) of their right and left shoulders. Maximum thickness was measured in both the long- and short-axis views. On the long-axis view, measurement was taken at the point where there was maximal height observed at the footprint insertion. Mixed-model analysis of variance was used to test for differences in tendon thickness across factors. Post hoc contrasts were performed with a Tukey adjustment for the P values. The mean ± SD values, side-to-side difference, and difference between dominant and nondominant values were calculated and statistically analyzed for differences. Results: An ultrasound examination showed a significant 3-way interaction (P = .038) for view by side of hand dominance. Post hoc contrasts revealed that supraspinatus tendon thickness for right-handed pitchers in the long-axis view on the right side showed a mean value of 8.0 ± 0.32 mm versus the long-axis view on the left side of 6.5 ± 0.34 mm (P = .006) and the short-axis view on the right of 7.4 ± 0.40 mm versus the short-axis view on the left of 6.1 ± 0.26 mm (P = .036). Supraspinatus tendon thickness for left-handed pitchers in the long-axis view on the left side showed a mean value of 7.5 ± 0.59 mm versus the long-axis view on the right side of 5.9 ± 0.56 mm (P = .137) and the short-axis view on the left of 6.5 ± 0.45 mm versus the short-axis view on the right of 6.5 ± 0.68 mm (P = .999). Conclusions: A database of normal values for supraspinatus tendon thickness in collegiate baseball pitchers has been developed. The results are consistent with expectations when the dominant side is compared with the nondominant side for right-handed pitchers with increased tendon thickness noted on the dominant side. There was no side-to-side difference found in left-hand dominant pitchers.

Feasibility of First Metatarsophalangeal Joint Injections for Sesamoid Disorders: A Cadaveric Investigation - Corrected Proof

Michael K. Wempe, Jacob L. Sellon, Yusef A. Sayeed, Jay Smith — 2012-04-09

Objective: To determine whether accurately placed first metatarsophalangeal joint (MTPJ) injections consistently deliver injectate to the metatarsosesamoid articulations. Design: Prospective anatomic cadaver study. Setting: Procedural skills laboratory at a tertiary care academic institution. Participants: Five unembalmed cadaveric lower limb specimens, free from trauma, surgery, or major deformity of the medial forefoot. Methods: Ultrasound guidance was used to accurately inject the first MTPJs of each cadaveric specimen with diluted, blue-colored latex. At a minimum of 24 hours after injection, each specimen was dissected to determine whether the latex was present between the metatarsal head and sesamoid bones (metatarsosesamoid articulations). Main Outcome Measures: The presence or absence of latex within the first MTPJ and both the tibial and fibular metatarsosesamoid articulations. Results: In all 5 cadaveric specimens, ultrasound-guided first MTPJ injection accurately delivered latex into the first MTPJ. In addition, in each specimen, latex was seen between the metatarsal head and both the fibular and tibial sesamoid bones. Conclusions: Accurate first MTPJ injections reliably deliver latex to the articular surfaces of the metatarsosesamoid articulations. Clinicians administering diagnostic or therapeutic injections for patients with sesamoid disorders should consider injecting the first MTPJ as an alternative to direct metatarsosesamoid articulation injections.

Test-Retest Reliability of 3D Ultrasound Measurements of the Thoracic Spine - Corrected Proof

2012-04-05

Objective: To explore the reliability of the Zebris CMS 20 ultrasound analysis system with pointer application for measuring end-range flexion, end-range extension, and neutral kyphosis angle of the thoracic spine. Design: Test-retest reliability of ultrasound movement analysis with use of a point marker has been shown for the lumbar and cervical spines but not for the thoracic spine. The test-retest reliability in this study was measured within a 24-hour interval. Setting: The study was performed within the School of Physiotherapy in cooperation with the Orthopedic Department of our University Hospital. Participants: The thoracic spines of 28 healthy subjects were measured. Methods: Measurements for neutral kyphosis angle, end-range flexion, and end-range extension were taken once at each time point. The bone landmarks were palpated by one examiner and marked with a pointer containing 2 transmitters using a frequency of 40 kHz. A third transmitter was fixed to the pelvis, and 3 microphones were used as receiver. The real angle was calculated by the software. Bland-Altman plots with 95% limits of agreement, intraclass correlations (ICC), standard deviations of mean measurements, and standard error of measurements were used for statistical analyses. Main Outcome Measurements: Statistical parameters were used to judge reliability. Results: The mean kyphosis angle was 44.8° with a standard deviation of 17.3° at the first measurement and a mean of 45.8° with a standard deviation of 16.2° the following day. The ICC was high at 0.95 for the neutral kyphosis angle, and the Bland-Altman 95% limits of agreement were within clinical acceptable margins. The ICC was 0.71 for end-range flexion and 0.34 for end-range extension, whereas the Bland-Altman 95% limits of agreement were wider than with the static measurement of kyphosis. Compared with static measurements, the analysis of motion with 3-dimensional ultrasound showed an increased standard deviation for test-retest measurements. Conclusions: The test-retest reliability of ultrasound measuring of the neutral kyphosis angle of the thoracic spine was demonstrated within 24 hours. Bland-Altman 95% limits of agreement and the standard deviation of differences did not appear to be clinically acceptable for measuring flexion and extension.

Outcomes of Children With Complex Regional Pain Syndrome After Intensive Inpatient Rehabilitation - Corrected Proof

Valerie Brooke, Steven Janselewitz — 2012-04-05

Objective: To examine the effectiveness of an inpatient treatment program on eliminating pain and increasing function for children with complex regional pain syndrome. Design: A retrospective chart review and follow-up telephone survey. Setting: A tertiary care hospital. Patients: Retrospective chart review of 32 children admitted for treatment of complex regional pain syndrome. Nineteen completed the telephone survey. Intervention: Intensive inpatient physical and occupation therapy in conjunction with psychological counseling, art therapy, recreational therapy, and child life specialists who focused on improving physical function and conditioning, stress management, and the development of self-efficacy related to pain and stress. Main Outcome Measurements: Resolution of pain and restoration of full function by patient or family report. Results: All the children had failed various prior treatment approaches: 34% had resolution at the time of discharge; 78% of admissions and 89% of those with follow-up had eventual resolution of pain; and 95% had full restoration of physical function at a median time from start of treatment of 2 months. Seven had recurrence and 5 were able to resolve the recurrence without further intervention from the medical community. Conclusions: Intensive inpatient rehabilitation is effective for children with complex regional pain syndrome. Additional studies are necessary to compare this treatment with other approaches.

Posteroanterior Spinal Stiffness at T5, T10, and L3 Levels in Normal Subjects - Corrected Proof

Shrawan Kumar — 2012-03-09

Objective: To measure, by using standardized device and protocol, posteroanterior (PA) spinal stiffness at the 5th and 10th thoracic (T5 and T10) and 3rd lumbar (L3) vertebral levels in asymptomatic adult volunteers. Design: A cross-sectional study. Setting: Osteopathic Heritage Foundation Physical Medicine Core Research Laboratory where the Therapeutic Spinal Mobilizer was fabricated to standardize the testing protocol. Participants: Sixteen asymptomatic adult volunteers. Methods: Volunteers were in the prone position on the treatment plinth and the loading block of the loading piston was placed at T5, T10, and L3. The subjects were instructed to remain still, to not contract any muscle, and to stop breathing mid cycle for 15 seconds when the data acquisition was initiated for a 10-second test cycle. The force was measured by using the load cell, and the spinal deformation was measured by the linear variable differential transducer. The data were extracted and subjected to descriptive statistics and analysis of variance to determine the effect of independent variables on spinal stiffness. Results: The PA spinal stiffnesses at 3 spinal levels were significantly different from each other (P < .0001). The spinal stiffness was significantly affected by the testing load, age, gender, and body weight of the subjects (P < .0001). The PA stiffness of the entire sample at 3 spinal levels ranged from 4.8-8.8 N/mm. The spinal stiffness values could be predicted as the function of testing load and body weight (P < .01). Conclusions: The PA spinal stiffness was significantly affected by spinal level, testing load, age, gender, and body weight (P < .0001).

Randomized Controlled Trial Comparing Acupuncture With Placebo Acupuncture for the Treatment of Carpal Tunnel Syndrome - Corrected Proof

2012-03-09

Objective: To investigate the efficacy of acupuncture for the treatment of mild to moderate carpal tunnel syndrome (CTS). Design: Prospective, randomized, placebo-controlled, double-blinded study. Setting: Single-center study. Participants: Forty-one acupuncture-naïve adult subjects with mild to moderate CTS enrolled in the study. Thirty-four subjects completed the study. Methods: Clinical diagnosis of CTS was supported by electrodiagnostic findings. Subjects were randomly assigned to either (1) acupuncture (n = 21) or (2) placebo acupuncture (n = 20) with use of Streitberger placebo acupuncture needles. Both groups received weekly sessions of acupuncture for 6 weeks. Wrist braces were provided to both groups to wear at night, and compliance was monitored. Main Outcome Measurements: The primary outcome measurement was subject-reported change in the Carpal Tunnel Self Assessment Questionnaire (CTSAQ) Symptom and Function scales immediately after and 2 weeks and 3 months after the final treatment. The secondary outcomes included tip and key pinch strength and combined sensory index. Results: Compared with pretreatment baseline values, subjects in the acupuncture group had 0.58 improvement (P = .03) on the CTSAQ Symptom scale score at 3 months after the last treatment, whereas 0.81 improvement (P = .001) was noted in the placebo acupuncture group. No statistically significant difference was found between the groups treated with acupuncture and placebo acupuncture with respect to improvement in CTS symptoms, function, tip/key pinch, or combined sensory index. Conclusions: To our knowledge, this study is the first randomized, placebo-controlled, double-blinded prospective study of traditional acupuncture for CTS. Both the treatment and placebo groups demonstrated improvements from baseline. Acupuncture was not shown to be superior to placebo acupuncture when used in conjunction with bracing for patients with mild to moderate CTS.

Is It Time to Rethink the Typical Course of Low Back Pain? - Corrected Proof

Ronald Donelson, Greg McIntosh, Hamilton Hall — 2012-03-02

Objective: To determine the frequency and the characteristics of low back pain (LBP) recurrences. The research questions were as follows: (1) Are LBP recurrences common? (2) Do episodes worsen with multiple recurrences? (3) Does pain change location in any recognizable pattern during an episode? Design: Single-page self-administered questionnaire. Setting: Thirty clinical practices (primary care, physical therapy, chiropractic, and surgical spine) in North America and Europe. Patients: A convenience sample of 589 respondents with LBP. There were no exclusions based on type of LBP, history of onset, or comorbidities. Methods: The survey was distributed during patients' assessment or initial treatment at their respective clinics. The survey queried the following: (1) the severity of original versus most recent episodes based on the following: pain intensity, interference with leisure and work activities, duration of episodes, and most distal extent of pain; and (2) changes in pain location within episodes. Results: In response to research question 1, a previous episode was reported by 73%; of those, 65.1% reported their first episode lasted ≤3 months, 54% repoted ≥10 episodes, and 19.4% reported >50 episodes. In response to research question 2. of those with recurrences, 61.1% reported that at least one of the survey domains was worse in recent episodes (P < .01) and only 36.9% reported that they were better; 20.9% were worse in all domains, whereas 8.6% were better or the same. In response to research question 3, the pain location changed during the episode in 75.6%; of these, 63.2% reported that their pain first spread distally before retreating proximally during recovery; there was a strong trend toward those reporting worsening episodes also reporting proximal-to-distal-to-proximal changes in pain location during their episodes (r = 0.132, P < .06). Conclusion: Recurrent LBP episodes were common and numerous. Recurrences often worsened over time. It seems inappropriate to characterize the typical course of LBP as benign and favorable.

Positive Effects of a Musculoskeletal Pain Rehabilitation Program Regardless of Pain Duration or Diagnosis - Corrected Proof

Elisabeth Persson, Jan Lexell, Mona Eklund, Marcelo Rivano-Fischer — 2012-02-20

Objectives: To investigate how sociodemographic and clinical factors are associated with psychosocial functioning and disability at admission to a musculoskeletal pain rehabilitation program and at 1-year follow-up. Design: A cohort pre-post study. Setting: A University hospital specialized pain rehabilitation unit. Participants: Five hundred nine participants with musculoskeletal pain (neck disorders, 29%; fibromyalgia, 24%; low back pain, 24%; myalgia, 14%; and other pain diagnoses, 8%). Intervention: A 5-week outpatient, group-based, and goal-oriented comprehensive musculoskeletal interdisciplinary pain rehabilitation program based on cognitive behavioral principles. Main Outcome Measures: The Multidimensional Pain Inventory (MPI), the Disability Rating Index (DRI), and forms including sociodemographic factors (sex, age, ethnicity, marital status, educational level, and vocational situation) and clinical factors (pain duration and pain diagnoses). Data were analyzed with multivariate logistic regression. Results: At admission, factors associated with more positive scores on the MPI were being older than 40 years, being at work, being Nordic born, attainment of a higher educational level, and a diagnosis of fibromyalgia (compared with a neck disorder) (P < .05). Being at work and a diagnosis of fibromyalgia (compared with low back pain) were associated with more positive scores on the DRI (P < .05). On the basis of cut points for clinically important change on the MPI, participants rated themselves as most improved on the Affective Distress (52%), Life Control (49%), and Pain Severity (43%) subscales, and on the DRI index, the improvement rate was 22%. At the 1-year follow-up, neither sociodemographic nor clinical factors were associated with clinically important improvements of the MPI and the DRI, but younger age was related to deteriorations in pain severity. Conclusions: The lack of an association between sociodemographic and clinical factors and psychosocial functioning and disability at a 1-year follow-up after a musculoskeletal pain rehabilitation program suggests that the program was effective regardless of the participants' initial characteristics, except for age. The changes at the 1-year follow-up indicate that the program influenced the participants' psychosocial functioning more than their perception of disability.