ABSTRACTS
1997;8(2):89-93
Comprehensiveness, Uniformity and Standardization in the Evaluation of Patients with Complaints of Pain
Norman J. Marcus
An increasing number of physicians from a variety of disciplines are
specializing in the treatment of patients with pain, and reporting treatment
success using disparate interventions. Due to the lack of standardized
evaluations of patients with pain, however, it has been impossible to reasonably
assess the claims of any facility and even more difficult to compare the
types of treatments from a variety of treatment settings. This paper will
describe the process of the formation of the Uniform Outcome Measures Committee
of the American Academy of Pain Medicine. The deliberations of the Committee
and the status of the development of a data collection system package will
be described.
Keywords: Pain; pain treatment; outcomes
1997;8(2):95-107
The Reintroduction of an Exercise Program to Directly Treat Low Back Pain of Muscular Origin
Hans Kraus, Norman J. Marcus
Decades of debate have yet to yield a universal solution to the treatment
of low back pain, a problem that afflicts 80% of adults in the United States
at some point of their lives. Exercise, in general, has become widely recognized
as playing a large role in the rehabilitation of back pain sufferers. Yet,
there is no consensus on which types of exercises to utilize. Most exercise
techniques address the muscles with the specific purpose of impacting the
skeleton or the spinal cord and nerve roots, rather than the muscles themselves.
This reinforces the notion that muscles are not the direct source of pain,
but rather only reflect pathology elsewhere. We reintroduce a rational
exercise regimen first developed by Hans Kraus, MD in 1949. This regimen
was shaped over a period of several years, through usage by thousands of
back pain sufferers. It directly addresses specific trunk muscle deficiencies
and tension, which are postulated by the authors to be the major factors
producing low back pain. The exercise protocol has shown to be highly effective
and inexpensive to administer on a wide-scale basis. Recent clinical experiences
utilizing the Kraus techniques are discussed.
Keywords: Low back pain; trunk muscles; exercise
1997;8(2):109-123
The New York Pain Treatment Program Protocol: A Structured Physical Therapy Approach for Treating the Muscular Components of Chronic Pain Syndromes
Marek B. Wyszynski
Although myofascial pain syndrome (MPS) is the most common diagnosis
for injured workers, there is no uniform description or definition of MPS
in the medical literature. Often, the phrase myofascial pain is used to
describe a variety of difficult to classify pain syndromes, resulting in
confused and contradictory treatment approaches. Correct diagnosis and
successful treatment of patients suffering from MPS must be based on a
firm understanding of the muscular component of chronic pain syndromes.
The New York Pain Treatment Program protocol in use at Lenox Hill Hospital
is based on classification, diagnosis, and treatment guidelines, developed
by Dr. Hans Kraus, that recognize four types of muscle pain (tension, spasm,
deficiency, and trigger points). It is the author's hope that this presentation
will assist other clinicians in developing optimal rehabilitation programs.
Keywords: Myofascial pain syndrome; muscle; physical therapy
1997;8(2):125-133
A Review of Utilization of Diagnostic Imaging in the Evaluation of Patients with Back Pain: The When and What of Back Pain Imaging
Robert D. Zimmerman
Purpose: To review the indications for imaging in patients with
back pain. Methods: The author's experience as a clinical
neuroradiologist in dealing with both referring physicians and their
patients with back pain form the basis of this manuscript. Several texts
and recent peer reviewed papers dealing with imaging of the spine were
consulted. Results: There are controversies over when to image
and the appropriate imaging modality to be used. The author presents
his views on the sources of these controversies and his philosophy on
imaging patients with back pain. A brief review of the major imaging
findings in degenerative and non-degenerative causes of back pain is
presented. To fully appreciate and see examples
of these imaging findings, the reader should read texts devoted to spinal
imaging. Conclusion: Controversy over the decision of when to perform
imaging of patients with back pain persist. From the perspective of the
radiologist there is little controversy over the choice of imaging studies
to be performed. MRI is superior to all other tests in the identification
of degenerative and non-degenerative causes of back pain. CT without intrathecal
contrast is an excellent test for degenerative disease but will often fail
to detect non-degenerative (e.g. neoplastic) causes of back pain.
Keywords: Low back pain; sciatica; herniated nucleus pulposus; spinal
stenosis; MRI; CT
1997;8(2):135-149
Epidural Steroid Injections for the Treatment of Lumbosacral Radiculopathy
Stephen E. Abram
Objective: While there is an extensive body of literature concerning
the use of epidural steroid injections in the treatment of sciatica, most
of the literature is descriptive or anecdotal. There are few controlled
studies regarding efficacy of this treatment modality. While there are
few published reports of serious complications of this therapy, warnings
about the hazards of epidural steroid injections occasionally appear in
both medical and lay literature. It is the purpose of this review to assess
the existing evidence for efficacy of epidural steroid injections for sciatica
and to assess the risks of this procedure. Data sources: Peer reviewed
medical literature from 1930 to the present was reviewed in order to survey
reports regarding pathophysiology of radiculopathy, mechanism of action
of epidural corticosteroids, controlled efficacy studies, reports on series
of epidural steroid injections for sciatica, reports of adverse effects
of epidural and intrathecal steroid injections, review articles of epidural
and intrathecal steroid injections, and studies of the behavioral and
histological effects of epidural steroids and their vehicle in animals.
Study selection:
Studies and review articles were selected from Medline search and from
the author's files of older literature. Data synthesis: Results
of this review are qualitative. It was felt that there was insufficient
controlled data to analyze efficacy or safety studies in a quantitative
fashion. Results: Radiculopathy following disc herniation appears
to produce either mechanical or chemical nerve root inflammation. Epidurally
injected corticosteroids most likely exert a beneficial effect through
anti-inflammatory rather than direct analgesic mechanisms. Most descriptive
studies report beneficial effects of epidural steroids in the majority
of cases of radiculopathy, but not for other causes of low back pain. Most
of the few controlled studies report epidural steroids to be more efficacious
than placebo or epidural local anesthetic alone. Most patients who respond
favorably continue to show improvement for many months. Several neurologic
complications have been reported after intrathecal steroid injections,
most following multiple intrathecal injections. Four cases of epidural
abscess, one case of bacterial meningitis, and one case of aseptic meningitis
have been reported following epidural steroid injections. Conclusions:
The majority of the published literature supports the notion that epidural
steroids provide relief of pain from lumbosacral radiculopathy. There is
anecdotal evidence that multiple intrathecal steroid injections may be
associated with neurological dysfunction, but there is very little evidence
that epidural steroids are neurotoxic.
Keywords: Epidural; corticosteroids; radiculopathy; efficacy; complications
1997;8(2):151-163
Algometry in the Daily Practice of Pain Management
Andrew A. Fischer
Purpose: this is a review article to update the clinical applications
of pressure pain sensitivity (PPS) measurement by pressure algometry (PA).
Basic procedures: The basic literature on pressure algometry has
been reviewed with emphasis on new developments. The author's and his
co-worker's
experience with PA, extending several years, are also included along with
some unpublished research results. Findings: The high reliability
and validity of PA for quantification of PPS has been proven by several
authors. The specificity and sensitivity of PA in detection of trigger
points (TrPs) is also very good. PA is also useful in evaluation of treatment
results. PA can document the decreased PPS after >preinjection (regional)
blocks= administered prior to trigger point injections (TPIs). A study
of ten patients with failed back surgery included 20 muscles. PA documented
long-term improvement (150 days) which corresponded to a decrease in pain
rating. Treatment consisted of needling and infiltration of the entire
trigger point (TrP) extending to taut band. Another study showed that physicians
were unable to produce 4 kg of pressure, which is critical for diagnosis
of fibromyalgia. Conclusions: Quantification of fibromyalgia diagnosis
by PA is necessary for abnormal tenderness (pain on 4 kg pressure). The
critical pressure for TrP, tender spots is a pressure pain threshold lower
by 2 kg/cm2 relative to a normally sensitive corresponding control
point.
1997;8(2):165-171
Therapeutic Trials with Thyroid Hormones in Chemically Euthyroid Patients with Myofascial Pain and Complaints Suggesting Mild Thyroid Insufficiency
Lawrence S. Sonkin
Objective: To determine why patients with normal function of the pituitary-thyroid
axis, myofascial pain, and other symptoms resembling those of hypothyroidism
respond to a slightly supraphysiological dose of levothyroxin administration.
Design: Review and analysis of author's records drawn from a data base
of therapeutic trials. Intervention: Oral administration of levothyroxin,
0.2. mg daily for at least 3 months. Main Outcome Measures: Patient interviews
and physical examinations by author. Measurement of differences in paired
BMR, serum cholesterol, and subjective response after 3 or more months
of thyroid hormone administration, using each patient as his or her own
control. Summary: Fifty-seven chemically euthyroid adults of both sexes
with myofascial pain and hypothyroid-like symptoms were treated with a
slightly supraphysiological dose, 0.2. mg, of levothyroxin daily. Cases
were selected recently from a database of 367 therapeutic trials performed
by the author between 1954 and 1983. All patients had a normal thyroid
profile, and a serum TSH measurement before initiating levothyroxin replacement.
BMRs and serum cholesterol determinations before and after at least 3 months
of thyroid hormone therapy were compared. A graph was constructed in which
each point displayed three responses for each patient: change in resting
oxygen consumption, following a 12-h fast (BMR); change in serum cholesterol;
and symptom response score. Thirteen TSH levels were slightly elevated.
Analysis of the graph suggests that almost all patients with: (1) normal
function of the pituitary thyroid axis; (2) non-inflammatory myofascial
pain refractory to physical medicine and trigger point therapy; and (3)
symptoms and signs resembling hypothyroidism, responded to thyroid hormone
therapy. The responses suggest correction of a peripheral block to thyroid
hormone in patients with normal pituitary thyrotroph function.
Keywords: Levothyroxin; TSH; pituitary; peripheral resistance; thyrotrophs; myofascial; BMR; serum cholesterol
Journal of Back and Musculoskeletal Rehabilitation