Faculty Bibliography

Significant numbers of patients with chronic LBP are caught in a steady state of receiving long-term opioids vs. serial spinal steroid injections. Given efforts reduce healthcare costs and minimize AE, it is imperative that the outcomes from these two treatment arms be compared using the same criteria. Objectives: examine outcomes related to analgesia, function, mortality, and AE. Methods: Relevant databases were searched. Articles meeting following criteria were selected for review: (1) open-label or blind prospective RCT (2) subjects diagnosed with non-neoplastic LBP or lumbar radiculopathy, aged >18, and treated with oral opioids or spinal steroid injections. Results: Eight high-quality and 10 moderatequality RCTs were identified. Patients receiving spinal steroid injections' pain decreased by VAS, by 7.18[95%CI 2.21-12.1] points greater than the control at <1 month and by 0.429[95%CI (-)4.41-5.27] points at 1-3 months. At >6 months no significant benefit 0.930[95%CI (-)5.03-6.89]. High-quality study on oral opioids showed improvements in patients' analgesia. Spinal steroids decreased ODI by 3.53[95%CI 0.480-6.57] at <1 month, by (-)0.281[95%CI (-)3.18-2.62] at 1-3 months, by (-)11.0[95%CI (-)14.8-(-)7.16] at 3-6 months, and by (-)0.205[95%CI (-)3.50-3.09] at >=6 months, suggesting short-term improvement in function. High-quality study on opioids showed improved function. More AE associated with opioid use but no mortality with either intervention. Conclusions: Oral opioids helpful for treatment of LBP but there are limitations due to AE. Spinal steroid injections beneficial for LBP and disability in the short-term. High dropout rates from insufficient pain relief suggest that opioids may not be as effective as spinal steroids for LBP. There is more high-quality literature to support use of spinal steroid injections compared to oral opioids

BACKGROUND: The primary objective of this pilot study is to understand the relationship between physicians' characteristics and physicians' management decisions about pain. The secondary aim is to understand how patient characteristics, including race/ethnicity and socioeconomic status (SES) may affect these treatment decisions in chronic low back pain. METHODS: We conducted a double-blinded randomized controlled study using a survey instrument. Ninety physicians were randomly allocated one of two scenarios of a patient with chronic low back and lower extremity pain. In one version, the patient is a Caucasian male with Blue Cross health insurance. In the other version, the patient is an African American male with Medicaid. All other aspects of the survey scenarios are identical. The physicians were subsequently presented with questionnaires about their treatment plans. We analyzed the physician demographic variables in addition to patient ethnicity and SES to differentiate which variables affected treatment preferences. RESULTS: Based on bivariate analysis, physician specialty, gender, ethnicity, and professional status significantly affected treatment plans, including analgesic prescription and referrals for invasive therapy. Patient ethnicity/SES trended toward significance for the prescription of opioids. CONCLUSION: Our study is the first randomized controlled study assessing patient and treatment variables in the management of chronic pain. It suggests that physicians' demographic variables and perhaps patient demographic variables influence pain management decisions

PURPOSE: To explore the option of using anticonvulsant drugs to modulate pain from corneal erosions. METHODS: N.M. is a 28-year-old woman with posttraumatic recurrent corneal erosions treated with bandage contact lenses, Muro-128, topical ketorolac, doxycycline, stromal micropuncture, and laser epithelial keratomileusis over the course of 4 years. Because of persistent episodes of corneal pain, she was prescribed topiramate. RESULTS: Before starting topiramate therapy, N.M. had experienced 3-4 awakenings at night because of pain and 5-6 episodes of spontaneous tearing and pain during the day. She started topiramate at 25 mg orally 4 times a day without significant change in her symptoms. After 1 week, the dose was escalated to 50 mg orally 4 times a day, and within 1 day, she experienced 0-1 awakenings at night. She had approximately 2-3 episodes of pain and tearing during the day. The dose was escalated to 100 mg orally 4 times a day. At that dose, the patient continued to have pain relief but complained of nausea. The patient's topiramate was weaned off to determine whether her symptom relief was caused by the medication or improvement in her condition. Once off the topiramate, N.M.'s nausea resolved but her corneal symptoms returned at the same frequency as before the initiation of topiramate. Therefore, she was restarted on topiramate 50 mg orally 4 times a day with rapid onset of improvement in her symptoms. CONCLUSIONS: Anticonvulsants such as topiramate may be effective in the management of pain caused by recurrent corneal erosions

This case series describes the inpatient rehabilitation of two medically complex patients with Parkinson's disease (PD) who had undergone deep brain stimulator (DBS) placement. Most patients may not require inpatient rehabilitation. However, a short rehabilitation stay might be of use to patients who need to be weaned off medications or who need frequent adjustments of their deep brain stimulators. This is the first case series to describe the inpatient rehabilitation of patients with deep brain stimulators

OBJECTIVE: To pilot methodologies designed to critically assess the American College of Rheumatology's (ACR) diagnostic criteria for fibromyalgia. DESIGN: Prospective, psychophysical testing. SETTING: An urban teaching hospital. SUBJECTS: Twenty-five patients with fibromyalgia and 31 healthy controls (convenience sample). INTERVENTIONS: Pressure pain threshold was determined at the 18 ACR tender points and five sham points using an algometer (dolorimeter). OUTCOME MEASURES: The patients 'algometric total scores' (sums of the patients' average pain thresholds at the 18 tender points) were derived, as well as pain thresholds across sham points. RESULTS: The 'algometric total score' could differentiate patients with fibromyalgia from normals with an accuracy of 85.7% (P < 0.001). Even a single tender point had a diagnostic accuracy between 75% and 89%. Although fibromyalgics had less pain across sham points than across ACR tender points, sham points also could be used for diagnosis (85.7%; Ps < 0.001). Hierarchical cluster analysis showed that three points could be used for a classification accuracy equivalent to the use of all 18 points. CONCLUSIONS: There was a significant difference in the 'algometric total score' between patients with fibromyalgia and controls, and we suggest this quantified (although subjective) approach may represent a significant improvement over the current diagnostic scheme, but this must be tested vs other painful conditions. The points specified by the ACR were only modestly superior to sham points in making the diagnosis. Most importantly, this pilot suggests single points, smaller groups of points, or sham points may be as effective in diagnosing fibromyalgia as the use of all 18 points, and suggests methodologies to definitively test that hypothesis

Characterized by chronic widespread joint and muscle pain, fibromyalgia is a syndrome of unknown etiology. The American College of Rheumatology's classification criteria for fibromyalgia include diffuse soft tissue pain of at least 3 months' duration and pain on palpation in at least 11 of 18 paired tender points. Symptoms are often exacerbated by exertion, stress, lack of sleep, and weather changes. Fibromyalgia is primarily a diagnosis of exclusion, established only after other causes of joint or muscle pain are ruled out. The initial workup for patients who present with widespread musculoskeletal pain should include a complete blood count, erythrocyte sedimentation rate, liver function tests, hepatitis C antibody, calcium, and thyrotropin. The musculoskeletal system, the neuroendocrine system, and the central nervous system, particularly the limbic system, appear to play major roles in the pathogenesis of fibromyalgia. The goal in treating fibromyalgia is to decrease pain and to increase function without promoting polypharmacy. Brief interdisciplinary programs have been shown to improve subjective pain. Fibromyalgia is a complex syndrome associated with significant impairment on quality of life and function and substantial financial costs. Once the diagnosis is made, providers should aim to increase patients' function and minimize pain. This can be accomplished through nonpharmacological ahd pharmacological interventions. With proper management, the rate of disability appears to be significantly reduced

OBJECTIVE: This pilot study assessed the opinions of medical students, residents, and attending physicians regarding the technical standards for medical school admission and the competencies required of graduates in the context of physical disability issues. DESIGN: Students, residents, and faculty from all specialties at a major academic medical center were surveyed regarding the concept of the 'undifferentiated graduate;' the relative importance of motor, sensory, observation, and communication skills; the importance of specific technical skills; and the use of physician extenders and other accommodations to fulfill technical standards. RESULTS: Respondents placed higher importance on observation and communication skills compared with motor skills. Of respondents, 69.8% either disagree or strongly disagree with the idea that a medical student should be an undifferentiated candidate possessing all the technical skills necessary to enter any specialty. CONCLUSIONS: Technical skills used in interpretation and observation were more important to respondents than those technical skills that are purely procedural. Respondents largely rejected the concept of the undifferentiated graduate. Although statistical analyses are of limited reliability because of low response rates, this study represents the most extensive sampling to date of medical professionals' opinions on these issues. Respondents' narrative comments also provided valuable perspectives