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issue 2 February 2015 Editorial: Where do we
Draw the Line
TNE Making a Splash
Clinical Conference 2015
Physiotherapy Associates is
Where do we Draw the Line? A Pain Story From Israel
I am at one of those points in my professional life once more and ask what is the meaning Course Schedule 2014/2015
of things? Throughout my career, I have been privileged to be exposed, taught and shaped by some of the most influential minds of our time in the physical therapy world. These exposures have culminated in a unique perspective on Test-retest reliability of pain
human pain and suffering, via the lenses of neuroscience. As I ponder my growth, I reflect Prognosis in patients with
chronic non-specific LBP
on a constant in my daily thoughts and ask at what point do we cross the line? Where should What used to work stopped working, likely Pharmacologic interventions
we draw the ethical compass when it comes to due to me not pushing hard enough. Talk about for knee osteoarthritis
treating people who suffer, especially people wheels coming off…I was still convinced with persistent pain? I'll explain more at the end that the Maitland Approach was superior and Predictive factors of chronic
– but for now…a historical (Adriaan) view of all I needed was to try harder and be better at physical therapy.
it and get a good run of normal patients again. Postoperative pain after total
PHASE 1: TEACHErS AND MAITLAND
Although challenged in this phase, I was still My training was incredible. As I travel the globe convinced what I was doing was right and many and experience various people's "upbringing" in others were wrong.
Pharmacotherapy for neuro-
PT, I revel in my original school training. Our pathic pain in adults
PHASE 3: GIFForD'S MATurE orGANISM
training was intense and focused on the minutia MoDEL
Trends in opioid analgesic abuse
of the Maitland Concept: "Find it; fix it". I No hyperbole here – while attending a remember the first few years treating people. Mobilization of the Nervous System course Baseline pain intensity in individu-
The Concept worked and clinically I was fixing als with DrF
the world. The important issue is that I had a continued on next page singular view of PT and musculoskeletal pain National trends in the surgical
and what I did was RIGHT and everything treatment for lumbar DDD
else was WRONG, especially PT's having the audacity to bend people backwards! This was opioids for low back pain
simple – black and white.
PHASE 2: IT DoES NoT Work!
The second phase encompassed many failures. Look for a Big
ANNouNCEMENT FroM
Adriaan Louw PT, PhD, CSMT ispinstitute.com 1 in Dallas, TX, David Butler presented constantly inundated with such questions are prevalent in our profession, such as SI Gifford's Mature Organism Model. Five at courses – what do you think of the [xxx joint positional faults, or restoring posture, minutes into the class I was hooked. name] approach. As a scientist, I know weak abdominals and so forth.
Finally – a model that made sense. This what the evidence tells me and it would was a larger view of pain allowing various thus be easy to dismiss a certain approach. What sparked this editorial? Recently I issues into a patient's pain experience, I usually, and likely correctly, answer that was confronted with this exact issue by such as culture, past experiences, all approaches are tools, aimed to facilitate a therapist I know quite well. He seems memories, etc. Although glued together change and could at the right time and with to have it all together – sharp as a whip; via Maitland clinical reasoning, this model the right patient have a tremendous effect. well-read in terms of pain science and at a allowed more freedom and in general a This now has brought me to a cross-road.
recent course a true pleasure having in the more rounded and open approach to the audience and worst of all….so young! He suffering person sitting in front of me. This PHASE 4 (?) THE CroSS roAD is likely to be a superstar one day for sure.
was the start of a greyer phase. Suddenly At what point to we have to use a moral, He was ranting and raving over a course definite yes and no was replaced by maybe, ethical compass? Pain science education he attended and in many ways believed or I don't know, but sounds probable. This aims to help people understand more about that what he has "found" is the holy grail model has since culminated in taking on the biology and physiology of pain. This is of treating people with pain. Not only does the brain, complex neurobiology, my own correct. What people often forget is that the approach being offered fail to provide studies and a PhD. What a great place to be pain education often includes unlearning any clinical or biological evidence, but the – anything and everything we do works, as previous faulty beliefs. We spend quite a approach will no doubt foster and likely long as we can reason it… bit of time helping patients see that various entrench poor beliefs in people who hurt beliefs they have are incorrect and likely and are in desperate need of help: I'll use a controversial example - not a major source of their pain experience. craniosacral therapy. On every scientific A good example is the old bulging disc Good posture = no/little pain level craniosacral therapy fails, including model. No amount of information on Bad posture = lots of pain clinical trials and animal studies sensitive nerves, stress biology and how examining cranial sutures and more. the brain deals with threat wil help Not only have we shown this assumption Skeptical readers can consult Tim Flynn's a patient who TRULY BELIEVES to have a very poor correlation, therapists editorial in JOSPT a few years ago. From they have pain due to the bulging disc. cannot agree over what constitutes or a neuroscience perspective, my newfound Pain education thus first (often) undoes how to assess posture (See for example grey perspective would argue that a well- these beliefs, and then embarks on the O'Sullivan in Manual Therapy Journal), meaning therapist that listens to a patient patient's reconceptualization of pain. This but I must wonder how this educational and truly cares will create a safe, healing then brings me to the main point of the model may make his patients….worse. So and accepting environment. Mix in it editorial: at what point is your approach I am humbly asking our readers to help an hands-on (craniosacral) treatment and it not only not helping but fueling incorrect old, not-so-smart neuroscience researcher may indeed provide a catalyst for recovery. beliefs in your patient? Sure it may help and clinician answer the questions: where The mechanism is likely to include a little – for a while - but may over time do we draw the line? Where is it ethically various cognitive influences such as fear become so entrenched it cripples a patient immoral to do this? Please let me know.
reduction, acceptance and more. I am for life! In my opinion, several of these Come join us at CSM 2015 in indianapolis Booth #1544
In just a few days the APTA's annual
Combined Sections Meeting will be held
in Indianapolis, IN. Come join ISPI for a
fun-filled week of learning, socialization,
fun, friendship and discussion. Stop by
the ISPI booth where you can talk to ISPI
faculty, staff and fellow therapists.
TNE Making a Splash…in the right Place!
At our pain classes people often bring
up the issue of: How do we get doc- tors onboard with TNE? One part of the process is having them view and become aware of the evidence. In December 2011 we published a sys- tematic review of pain neuroscience education, which has gained a lot of interest in the physical therapy world. What may be uplifting for therapists to know is that the paper has been a "hot commodity" in the medical world and since 2012 been in the top 25 most tor, Archives publishes more articles tation Reports. What's even more im- downloaded papers in The Archives of annually than any other rehabilitation pressive is that the paper has moved Physical Medicine and Rehabilitation journal, and is the most highly cited up this past year from number 23 to as calculated by article downloads on journal in the Rehabilitation category number 11! SciVerse ScienceDirect. Per the edi- of the Thomson Reuters Journal Ci- ispinstitute.com 3 Test-retest reliability
participated. Each patient shaded two in CNP. There was no relation between of pain extent and pain
consecutive PDs using a digital tablet. pain extent and the level of distress or Software was developed to quantify cognitive function.
location using a novel
the pain extent, to analyse the pain overlap between PDs and to produce CoNCLuSIoNS: A novel method for
method for pain drawing pain frequency maps. Correlations the acquisition of PD was presented.
were obtained between pain extent Test-retest reliability of reporting pain and clinical features including the extent and pain location was supported Eur J Pain. 2015 Jan 6. doi: 10.1002/ejp.636 level of pain intensity, disability, and in people with CNP and CLBP. psychological distress and cognitive Future research is needed to establish Pain drawings (PDs) are an important function.
psychometric properties of PD.
component of the assessment of a patient with pain. The aim of this work rESuLTS: The intraclass correlation
is to present the test-retest reliability of a coefficients for pain extent in CLBP novel method of quantifying the extent and CNP were very high: 0.97 (95% and location of pain. Additionally, the CI: 0.95-0.98) and 0.92 (95% CI: 0.87- association between PD variables and 0.98), respectively. The Bland Altman clinical features in patients with chronic showed a mean difference close to neck pain (CNP) and chronic low back zero: 5.4% pixels in CNP group and 3% pain (CLBP) was explored.
pixels in the CLBP group. Significant correlations were observed between METHoDS: Fifty-one patients with pain extent and pain intensity in CLBP
CLBP and 56 patients with CNP and CNP and pain extent and disability Prognosis and course of pain in patients with chronic non-specific
low back pain: A 1-year follow-up cohort study.
Eur J Pain. 2015 Jan 6. doi: 10.1002/ejp.633. BaCkgroUND: It remains unclear rESuLTS: Patient-reported intensity
to what extent patients recover from of back pain decreased from 55.5 (SD chronic non-specific low back pain 23.0) at baseline to 37.0 (SD 23.8), 35.3 (NSLBP). The objective of this study (SD 26.1) and 32.3 (SD 26.9) at 2-, 5- was to determine (1) the course of and 12-month follow-up, respectively. chronic NSLBP in tertiary care and Younger age, back pain at baseline, no (2) which factors predicted 5- and psychological/physical dysfunction 12-month outcomes.
(Symptom Check List-90, item 9), and higher baseline scores on the physical METHoDS: This prospective study component scale and mental component
includes 1760 chronic NSLBP patients scale of quality of life (Short Form-36) from a rehabilitation clinic (mean age were positively associated with recovery 40.1 years, SD 10.6). After baseline at 5 and 12 months. At 5-month follow- measurement, patients followed a up, higher work participation at baseline 2-month multidisciplinary therapy was also a prognostic factor for both program; evaluation took place at 2, 5 definitions of recovery. At 12-month and 12 months post baseline. Recovery follow-up, having co-morbidity was was defined as (1) relative recovery predictive for both definitions.
[30% improvement on the pain, visual analogue scale (VAS) compared with CoNCLuSIoN: The results of this
baseline] and (2) absolute recovery study indicate that in chronic NSLBP (VAS pain ≤ 10 mm). The multivariate patients, bio-psychosocial prognostic logistic regression analysis included factors may be important for clinicians 23 baseline characteristics.
when predicting recovery in back pain intensity during a 1-year period.
ispinstitute.com 4 Comparative Effectiveness of Pharmacologic Interventions
for knee osteoarthritis: A Systematic review and Network
Meta-analysis Ann Intern Med. 2015 Jan 6;162(1):46-54 BaCkgroUND: The relative efficacy DATA SourCES: MEDLINE, EM-
en, celecoxib, intra-articular (IA) cor- of available treatments of knee os- BASE, Web of Science, Google ticosteroids, IA hyaluronic acid, oral teoarthritis (OA) must be determined Scholar, Cochrane Central Register placebo, and IA placebo.
for rational treatment algorithms to be of Controlled Trials from inception through 15 August 2014, and unpub- DATA EXTrACTIoN: Two reviewers
lished data.
independently abstracted study data PurPoSE: To examine the efficacy of
and assessed study quality. Standard- treatments of primary knee OA using a STuDY SELECTIoN: Randomized tri-
ized mean differences were calculat- network meta-analysis design, which als of adults with knee OA comparing ed for pain, function, and stiffness at estimates relative effects of all treat- 2 or more of the following: acetamin- 3-month follow-up.
ments against each other.
ophen, diclofenac, ibuprofen, naprox- DATA SYNTHESIS: Network me-
ta-analysis was performed using a Bayesian random-effects model; 137 studies comprising 33 243 participants were identified. For pain, all interven- tions significantly outperformed oral placebo, with effect sizes from 0.63 continued on page 11 Prevalence and Predictive Factors of Chronic Postsurgical Pain
and Poor Global recovery one Year after outpatient Surgery
Clin J Pain. 2015 Jan 6
oBJECTiVES: To prospectively the Global Surgical Recovery Index preoperative and acute postoperative
describe the prevalence and predictive (GSR) was defined as poor global quality of life, and follow-up surgery factors of chronic postsurgical pain recovery.
during the first postoperative year.
(CPSP) and poor global recovery in a large outpatient population at rESuLTS: 908 patients were included. DISCuSSIoN: Moderate to severe
a university hospital, one year after The prevalence of moderate to CPSP after outpatient surgery outpatient surgery.
severe preoperative pain was 37.7%, is common, and should not be acute postsurgical pain 26.7%, underestimated. Patients at risk for METHoDS: A prospective longitudinal and CPSP 15.3%. Risk factors for developing CPSP can be identified
cohort study was performed. During the development of CPSP were during the preoperative phase.
eighteen months, patients presenting surgical specialty, preoperative pain, for preoperative assessment were preoperative analgesic use, acute invited to participate. Outcome postoperative pain, surgical fear, lack parameters were measured by using of optimism and poor preoperative questionnaires at three time points: quality of life. The prevalence of one week preoperatively, four poor global recovery was 22.3%. days postoperatively and one year Risk factors for poor global recovery postoperatively. A value of >3 on an were recurrent surgery because of 11-point numeric rating scale (NRS) the same pathology, preoperative was considered to indicate moderate pain, preoperative analgesic use, to severe pain. A score of ≤80% on surgical fear, lack of optimism, poor ispinstitute.com 5 isPi Clinical Conference 2015: every Joint has a brain June 19, 20 & 21, 2015 Hilton Minneapolis/Bloomington, MN Come learn to unlock the CHALLENGES
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Pre-surgical assessment of temporal summation of pain
predicts the development of chronic postoperative pain 12
months after total knee replacement.
Pain. 2015 Jan;156(1):55-61Patients with knee osteoarthritis fore surgery (P = 0.009) and 12 months demonstrate decreased pressure pain after surgery (P < 0.001). thresholds (PPTs), facilitated tempo- ral summation (TS) of pain, and de- The PPTs of the low-pain groups creased conditioned pain modulation were normalized for all measurement (CPM) compared with healthy con- sites comparing pre-surgery with 12 trols. This study aimed to correlate months post-surgery (P < 0.05, contra preoperative PPTs, TS, and CPM with lateral arm: P = 0.059), which was not the development of chronic postoper- the case for the high-pain group. The ative pain after total knee replacement low-pain group showed a functional inhibitory CPM preoperatively and 12 months postoperatively (P < 0.05), Knee pain intensity (visual analog which was not found in the high-pain scale [VAS]: 0-10), PPTs, TS, and group. The high-pain group had high- ate-to-severe pain had pro-nocicep- CPM were collected before, 2 months, er facilitated TS preoperatively and tive changes compared with patients and 12 months after TKR. Patients 12 months postoperatively compared who developed mild pain post-sur- were divided into a low-pain (VAS < with the low-pain group (P < 0.05). gery. Preoperative TS level correlated 3) and a high-pain (VAS ≥ 3) group Preoperative TS level correlated to with the postoperative pain intensity based on their VAS 12 months after 12-month postoperative VAS (R = and may be a preoperative mechanis- TKR. The high-pain group (N = 17) 0.240, P = 0.037). tic predictor for the development of had higher pain intensities compared chronic postoperative pain in patients with the low-pain group (N = 61) be- Patients who developed moder- with osteoarthritis after TKR. Our Newest Patient Pain Resource Guide
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PHArMACoTHErAPY For NEuroPATHIC PAIN IN ADuLTS:
a SySTEMaTiC rEViEw aND METa-aNaLySiS
Lancet Neurol. 2015 Jan 6. pii: S1474-4422(14)70251-0
BaCkgroUND: New drug treatments, METHoDS: Between April, 2013, was calculated with the fixed-effects
clinical trials, and standards of and January, 2014, NeuPSIG of the Mantel-Haenszel method.
quality for assessment of evidence International Association for the Study justify an update of evidence- of Pain did a systematic review and FINDINGS: 229 studies were included
based recommendations for the meta-analysis of randomized, double- in the meta-analysis. Analysis of pharmacological treatment of blind studies of oral and topical publication bias suggested a 10% neuropathic pain. Using the Grading pharmacotherapy for neuropathic overstatement of treatment effects. of Recommendations Assessment, pain, including studies published in Studies published in peer-reviewed Development, and Evaluation peer-reviewed journals since January, journals reported greater effects (GRADE), we revised the Special 1966, and unpublished trials retrieved than did unpublished studies (r2 Interest Group on Neuropathic Pain from ClinicalTrials.gov and websites 9•3%, p=0•009). Trial outcomes (NeuPSIG) recommendations for the of pharmaceutical companies. We were generally modest: in particular, pharmacotherapy of neuropathic pain used number needed to treat (NNT) for combined NNTs were 6•4 (95% CI based on the results of a systematic 50% pain relief as a primary measure review and meta-analysis.
and assessed publication bias; NNT continued on page 12 Trends in opioid analgesic abuse and mortality in the united States
N Engl J Med. 2015 Jan 15;372(3):241-8 BaCkgroUND: The use of The programs gather data from diversion and abuse of prescription
prescription opioid medications has drug-diversion investigators, poison opioid medications increased between increased greatly in the United States centers, substance-abuse treatment 2002 and 2010 and plateaued or during the past two decades; in 2010, centers, and college students.
decreased between 2011 and 2013. there were 16,651 opioid-related These findings suggest that the United deaths. In response, hundreds of rESuLTS: Prescriptions for opioid States may be making progress
federal, state, and local interventions analgesics increased substantially in controlling the abuse of opioid have been implemented. We describe from 2002 through 2010 in the United analgesics. (Funded by the Denver trends in the diversion and abuse of States but then decreased slightly Health and Hospital Authority.) prescription opioid analgesics using from 2011 through 2013. In general, data through 2013.
RADARS System programs reported large increases in the rates of opioid METHoDS: We used five programs diversion and abuse from 2002 to
from the Researched Abuse, Diversion, 2010, but then the rates flattened or and Addiction-Related Surveillance decreased from 2011 through 2013. (RADARS) System to describe The rate of opioid-related deaths rose trends between 2002 and 2013 in the and fell in a similar pattern. Reported diversion and abuse of all products nonmedical use did not change and formulations of six prescription significantly among college students.
opioid analgesics: oxycodone, hydrocodone, hydromorphone, CoNCLuSIoNS: Post-marketing
fentanyl, morphine, and tramadol. surveillance indicates that the ispinstitute.com 9 Baseline Pain intensity is a Predictor of Chronic Pain in individuals with Distal radius fracture
J Orthop Sports Phys Ther. 2015 Jan 8:1-30 continue to experience wrist/hand operating characteristic (ROC) pain and functional impairments even curves examined the sensitivity/ 1 year after DRF. Early identification specificity of baseline pain intensity in of individuals at risk of these adverse predicting chronic pain and functional outcomes can facilitate the delivery of impairment. required interventions to mitigate the risk. rESuLTS: Required data was
METHoDS: Data for the Patient-
available for 386 individuals. STuDY DESIGN: Secondary analysis of rated Wrist Evaluation (PRWE) (for Baseline pain intensity was found to
both the pain and function scales of be a strong predictor of chronic pain PRWE) at baseline and 1 year after explaining 22% of the variance. A oBJECTiVE: This study examined DRF, age, sex, injury to the dominant baseline score of 35 (out of 50) on
whether baseline pain intensity is a side, presence of comorbidity, the pain subscale of the PRWE had predictor of chronic pain and wrist/ education level, mechanism of the best sensitivity/specificity cut-off hand functions at 1 year following fracture, smoking status, fall history, values (85/79) for predicting chronic distal radius fracture (DRF). The or energy of fracture were extracted pain at 1 year after DRF. study also examined the cut-off level from an existing dataset. Multivariate for baseline pain intensity that was regression analysis examined the CoNCLuSIoN: Rehabilitation prac-
best predictive of chronic pain. utility of baseline pain intensity and titioners may be able to use the score the above variables in predicting of >35/50 on the PRWE Pain Scale to BaCkgroUND: Many individuals pain and functional status at 1 year screen individuals at risk of chronic
in individuals with DRF. Receiver pain following DRF.
National trends in the surgical treatment for lumbar degenerative disc disease:
united States, 2000 to 2009. Spine J. 2015 Feb 1;15(2):265-71
BaCkgroUND CoNTEXT: Surgical or older with primary diagnosis of
treatment for lumbar degenerative disc lumbar/lumbosacral DDD who under- disease (DDD) remains controversial. went surgical treatment were included.
Options include anterior lumbar inter- body fusion, posterior approach fusion ouTCoME MEASurES: Trends in the
procedures such as posterior lumbar surgical treatment for lumbar DDD.
interbody fusion (PLIF) and postero- lateral lumbar fusion (PLF), anterior METHoDS: Clinical data were derived
and posterior lumbar fusion (APLF), from the NIS between 2000 and 2009. and total disc replacement (TDR). Patients aged 18 years or older with However, the trends during the last a primary diagnosis of lumbar/lum- decade are uncertain.
bosacral DDD who underwent spinal fold and PLIF/PLF increased 2.8-fold. fusion or TDR were identified. Data Total disc replacement did not increase PurPoSE: To examine the trends regarding patient- and health care sys-
significantly. Anterior lumbar inter- in the surgical treatment for lumbar tem-related characteristics were re- body fusion was performed in 16.8% DDD on a national level.
trieved and analyzed.
of patients, PLIF/PLF in 67.9%, APLF in 13.6%, and TDR in 1.8%. Surgical STuDY DESIGN: A retrospective anal-
rESuLTS: A total of 380,305 patients treatment for lumbar DDD was 1.8
ysis of population-based national hos- underwent surgical treatment for lum- times more common in the Midwest pital discharge data collected for the bar DDD between 2000 and 2009. Pop- region and 1.7 times more common in Nationwide Inpatient Sample (NIS).
ulation adjusted incidence increased the South region than in the Northeast PATIENT SAMPLE: In the NIS from 2.4-fold from 2000 to 2009. Among region. Total disc replacement was
2000 to 2009, patients aged 18 years the procedures, APLF increased 3.0- continued on next page ispinstitute.com 10 A Pain Story from Israel knee osteoarthritis
continued from page 5for the most efficacious treatment (hy- In the past 3 years I have had the privi- pital he kept complaining that his knee aluronic acid) to 0.18 for the least ef- lege to travel to/from Israel. All over the hurts really badly. No pain whatsoever ficacious treatment (acetaminophen). world people are interested in learning around the mess the bullets made. He For function, all interventions except more about pain. An Israeli PT friend, actually called his mom and told her he IA corticosteroids were significantly Nirit, sent me this and we thought it may was OK, but thought he injured his knee. superior to oral placebo. For stiffness, be worth sharing. It's a beautiful pain In the ER he told the physicians the same most of the treatments did not signifi- story about endogenous mechanisms, and insisted no pain around the horrific cantly differ from one another.
memory and attention – Adriaan. injury. None! He was treated at the hos- pital where I work. All through recovery LIMITATIoN: Lack of long-term data,
About a year ago I saw a 20 y old guy his leg bothered him more than anything inadequate reporting of safety data, for a consultation. The usual anterior else and otherwise he was much less possible publication bias, and few knee pain which got better with physio painful then could be expected. It was as head-to-head comparisons.
but he was worried of future damage if the original inhibition attenuated the etc. His aunt was a patient of mine. She later reaction. He is now at our outpa- CoNCLuSIoN: This method allowed
was a really bad CRPS patient who fully tient rehab. Lately it seems an orthope- comparison of common treatments of recovered so she told him to see me so dist has been putting nonsense into his knee OA according to their relative ef- I can tell him what's going on. We did mind regarding his back injury. Today ficacy. Intra-articular treatments were that, he was happy and did not need fur- he came in and told me he has a really superior to nonsteroidal anti-inflam- ther treatment.
bad back pain using "worried", "afraid matory drugs, possibly because of the " and such descriptives. So I told him integrated IA placebo effect. Small why he has many good reasons for back but robust differences were observed pain (neuroscience reasons of course), between active treatments. All treat- what it means and no reason to worry. ments except acetaminophen showed He wasn't sure so I did my favorite trick clinically significant improvement which is asked people around us, phys- from baseline pain. This information, ios and patients, if they had back pain along with the safety profiles and rela- in the last month. Of course everybody tive costs of included treatments, will said yes. So he said he got it, turned to be helpful for individualized patient his physio and asked for the session to care decisions.
focus on back exercise. He is a sweet kid, with good sense of humor and an Two months ago he was shot by a ter- amazing pain story which he gave per- National Surgical Trends
rorist. Close range, 3 bullets shattering mission for me and "all physios" to tell continued from page 10 his vena cava, hitting a vertebra with no anyone who might be interested or not. more common in younger patients and large damage but very small bone frag- He even offered to add his picture as in the Northeast region. Poterior lum- ments all around, shrapnel all over his in- he is "so good looking". Those patients bar interbody fusion/PLF was more ternal organs. Luckily for him the whole make what we do fun and so interesting.
common in older patients and in the mess pressed on his vena cava South region.
stopping massive bleeding up until he was in the operating CoNCLuSIoNS: During the last de-
room. It was still touch and go cade, surgical treatment for lumbar but his life was saved and after DDD has increased 2.4-fold in the 3 further operations he got on United States. Although all fusion pro- with his recovery. Altogether cedures significantly increased, TDR he got 43 blood transfusions! did not increase. Surgical treatment for lumbar DDD was more common The amazing thing is that he in the Midwest and South regions. did not lose consciousness and Trends in the procedures were differ- while he was taken to the hos- ent depending on the age group and hospital region.
ispinstitute.com 11 opioids for low back pain Neuropathic Pain in Adults
continued from page 9 BMJ. 2015 Jan 5;350:g6380 5•2-8•4) for serotonin-noradrenaline reuptake inhibitors, mainly including duloxetine (nine of 14 studies); 7•7 Back pain affects most adults, causes conditions is about 30%. Given the (6•5-9•4) for pregabalin; 7•2 (5•9- disability for some, and is a common brevity of randomized controlled 9•21) for gabapentin, including reason for seeking healthcare. In the trials, the long term effectiveness and gabapentin extended release and United States, opioid prescription safety of opioids are unknown. Loss enacarbil; and 10•6 (7•4-19•0) for for low back pain has increased, and of long term efficacy could result capsaicin high-concentration patches. opioids are now the most commonly from drug tolerance and emergence of NNTs were lower for tricyclic prescribed drug class. More than half hyperalgesia. antidepressants, strong opioids, of regular opioid users report back tramadol, and botulinum toxin A, and pain. Rates of opioid prescribing in the Complications of opioid use include undetermined for lidocaine patches. US and Canada are two to three times addiction and overdose related Based on GRADE, final quality of higher than in most European countries. mortality, which have risen in parallel evidence was moderate or high for with prescription rates. Common short all treatments apart from lidocaine The analgesic efficacy of opioids term side effects are constipation, patches; tolerability and safety, and for acute back pain is inferred from nausea, sedation, and increased risk of values and preferences were higher for evidence in other acute pain conditions. falls and fractures. Longer term side topical drugs; and cost was lower for Opioids do not seem to expedite return effects may include depression and tricyclic antidepressants and tramadol. to work in injured workers or improve sexual dysfunction. Screening for high These findings permitted a strong functional outcomes of acute back pain risk patients, treatment agreements, and recommendation for use and proposal in primary care. For chronic back pain, urine testing have not reduced overall as first-line treatment in neuropathic systematic reviews find scant evidence rates of opioid prescribing, misuse, or pain for tricyclic antidepressants, of efficacy. Randomized controlled overdose. serotonin-noradrenaline reuptake trials have high dropout rates, brief inhibitors, pregabalin, and gabapentin; duration (four months or less), and Newer strategies for reducing risks a weak recommendation for use and highly selected patients. include more selective prescription proposal as second line for lidocaine of opioids and lower doses; use of patches, capsaicin high-concentration Opioids seem to have short term prescription monitoring programs; patches, and tramadol; and a weak analgesic efficacy for chronic back avoidance of co-prescription with recommendation for use and proposal pain, but benefits for function are sedative hypnotics; and reformulations as third line for strong opioids and less clear. The magnitude of pain that make drugs more difficult to snort, botulinum toxin A. Topical agents and relief across chronic non-cancer pain smoke, or inject.
botulinum toxin A are recommended for peripheral neuropathic pain only.
INTErPrETATIoN: Our results
support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain. Inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Modest efficacy, large placebo responses, heterogeneous diagnostic criteria, and poor phenotypic profiling probably account for moderate trial outcomes and should be taken into account in future studies.
ispinstitute.com 12 2015 Course schedule Therapeutic Neuroscience Education: Teaching People About Pain Therapeutic Neuroscience Education: Educating Patients About Pain A Study of Neurodynamics: The Body's Loving Alarm System Spinal Manipulation I: A Physical Therapy Approach The Whiplash Patient: An Update on Examination & Treatment The Lower Quadrant: A Differential Diagnosis Approach to Manual Therapy The Cervical Spine: A Manual Therapy and Pain Science Approach Spinal Manipulation I: A Physical Therapy Approach The Thoracic Spine: A Manual Therapy and Pain Science Approach The Lumbar Spine: A Manual Therapy and Pain Science Approach The Upper Quadrant: A Differential Diagnosis Approach to Manual Therapy Therapeutic Neuroscience Education: Educating Patients About Pain Why Do I Hurt? (2 hours)
Spinal Manipulation I: A Physical Therapy Approach A Therapeutic Treatment Approach to Cervicogenic Headaches Education and Exercise for Fibromyalgia Patients: A Neuroscience Approach Therapeutic Neuroscience Education: Educating Patients About Pain Why Do I Hurt? (2 hours) Too Hot to Handle: Desensitizing the Hypersensitive Patient The Cervical Spine: A Manual Therapy & Pain Science Approach Therapeutic Neuroscience Education: Educating Patients About Pain Therapeutic Neuroscience Education: Educating Patients About Pain Too Hot to Handle: Desensitizing the Hypersensitive Patient fri/Sat/Sun Jun 19-22
The Clinical Conference: Every Joint Has a Brain
Spinal Manipulation I: A Physical Therapy Approach The Thoracic Spine: A Manual Therapy and Pain Science Approach Fri/Sat/Sun Aug 21-23 Therapeutic Neuroscience Education: Educating Patients About Pain The Lumbar Spine: A Manual Therapy and Pain Science Approach Therapeutic Neuroscience Education I: Educating Patients About Pain A Study of Neurodynamics: The Body's Living Alarm Fountain Valley, CA The Upper Quadrant: A Differential Diagnosis Approach to Manual Therapy A Study of Neurodynamics: The Body's Living Alarm Philadelphia, PA A Study of Neurodynamics: The Body's Living Alarm Elbow, Wrist and Hand, Differential Diagnosis & Management The Cervical Spine: A Manual Therapy & Pain Science Approach Courses are still being scheduled, keep checking back if you don't see what you are looking for! If you are interested in hosting a one or two-day class at your facility, contact us.

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