Cognitive behavioral therapy for managing depressive and anxiety symptoms after brain injury: a meta-analysis

BACKGROUND

Individuals with traumatic brain injury (TBI) are at increased risk of depression and anxiety, leading to impaired recovery. While cognitive-behavioral therapy (CBT) addresses anxiety and depression maintenance factors, its efficacy among those with TBI has not been clearly demonstrated. This review aims to bridge this gap in the literature.

METHODS

Several databases, including Medline, PsycInfo and EMBASE, were used to identify studies published between 1990 and 2021. Studies were included if: (1) trials were randomized controlled trials (RCT) involving CBT-based intervention targeting anxiety and/or depression; (2) participants experienced brain injury at least 3-months previous; (3) participants were ≥18 years old. An SMD ± SE, 95% CI and heterogeneity were calculated for each outcome.

RESULTS

Thirteen RCTs were included in this meta-analysis. The pooled-sample analyses suggest that CBT interventions had small immediate post-treatment effects on reducing depression (SMD ± SE: 0.391 ± 0.126, p < 0.005) and anxiety (SMD ± SE: 0.247 ± 0.081, p < 0.005). Effects were sustained at a 3-months follow-up for depression. A larger effect for CBT was seen when compared with supportive therapy than control. Another sub-analysis found that individualized CBT resulted in a slightly higher effect compared to group-based CBT.

CONCLUSION

This meta-analysis provides substantial evidence for CBT in managing anxiety and depression post-TBI.

Quantification of needle angles for lumbar medial branch denervation targeting the posterior half of the superior articular process: an osteological study

BACKGROUND

Lumbar medial branch radiofrequency ablation (RFA) is a common intervention to manage chronic axial low back pain originating from the facet joints. A more parasagittal approach targeting the posterior half of the lateral neck of superior articular process (SAP) was previously proposed. However, specific needle angles to achieve parallel placement at this target site have not been investigated.

OBJECTIVE

To quantify and compare the needle angles, on posterior and lateral views, to achieve parallel placement of electrodes along the medial branch at the posterior half of the lateral neck of SAP at each lumbar vertebral level (L1-L5) and sacrum.

DESIGN

Osteological Study.

METHODS

Twelve disarticulated lumbosacral spines (n = 72 individual bones) were used in this study. Needles were placed along the periosteum of the posterior half of the lateral neck of SAP, bilaterally and photographed. Mean needle angles for each vertebral level (L1-L5) and sacrum were quantified, and statistical differences were analyzed.

RESULTS

The posterior view provided the degrees of lateral displacement from the parasagittal plane (abduction angle), while the lateral view provided the degrees of declination (cranial-to-caudal angle) of the needle. Mean needle angles at each level varied, ranging from 5.63 ± 5.76° to 14.50 ± 14.24° (abduction angle, posterior view) and 40.17 ± 7.32° to 64.10 ± 9.73° (cranial-to-caudal angle, lateral view). In posterior view, a < 10-degree needle angle interval was most frequently identified (57.0% of needle placements). In lateral view, the 40-50-degree (L1-L2), 50-60-degree (L3-L5), and 60-70-degree (sacrum) needle angle intervals occurred most frequently (54.2%, 50.0%, and 41.7% of needle placements, respectively).

CONCLUSIONS

Targeting the posterior half of the lateral neck of SAP required <10-degree angulation from parasagittal plane in majority of cases. However, variability of needle angles suggests a standard "one-size-fits-all" approach may not be the optimal technique.

Parasagittal needle placement approach for lumbar medial branch denervation: a brief technical report

Radiofrequency denervation of lumbar medial branches is a viable treatment option to manage chronic facetogenic low back pain. Traditionally, lumbar medial branch denervation involves placement of the electrode's active tip at a 20-degree angulation away from the parasagittal plane. However, more recent anatomical studies have provided evidence supporting the feasibility of an alternative parasagittal approach targeting the posterior half of the lateral neck of the superior articular process to capture the lumbar medial branches. Currently, there is a lack of clinical data on the effectiveness of the alternative parasagittal needle placement technique. Therefore, in this brief technical report, the parasagittal needle placement technique and the pain relief outcomes in four consecutive patients following treatment with the parasagittal approach are described.

Internet-based sexual health resources for those living with spinal cord injury: A content analysis

CONTEXT

Spinal cord injuries (SCIs) disrupt physiological functioning which can significantly impact sexuality. Those with SCI may rely heavily on Internet sexual health resources for many reasons. Evaluation of current internet health resources is warranted to identify the gaps in the literature.

OBJECTIVES

The aim of this study was to conduct a purposive review of available Internet sexual health resources for those with SCI.

METHODS

A Google search was completed with search terms such as: "SCI and sexual functioning", "SCI and sexuality", "SCI and pregnancy" and "SCI and sexual pleasure". Resources were selected if they: (1) provided sexual health education to those with SCI; (2) were designed to increase skills-based learning or influence attitudes and beliefs; and (3) in English language. All identified resources were imported to NVivo 1.5.1 where a thematic content analysis was conducted.

RESULTS

The search resulted in 123 resources meeting the criteria. The most common themes included: Sexual functioning (in 83.7% of resources), Reproductive health (67.5%) and Impact of Secondary Complications (61.8%). The least common themes were Psychosocial (24.4%), Stigma (13.8%), and Quality of Life (12.2%). No information was coded for LGBTQ+.

DISCUSSION

Sexual health and SCI information focuses primarily on heterosexual males and specifically on sexual functioning. Resources addressing female sexuality were extremely limited and focused largely on reproduction. There was a complete absence of resource aimed to address LGBTQ+ people.

CONCLUSION

The results demonstrate a need for Internet-based sexual health education resources to meet the needs of diverse individuals including women and gender non-conforming people.

The effect of neuropathic pain treatments on pain interference following spinal cord injury: A systematic review

CONTEXT

Neuropathic pain is a common and debilitating condition following SCI. While treatments for neuropathic pain intensity have been reviewed, the impact on pain interference has not been summarized.

OBJECTIVE

To systematically review the effect of neuropathic pain interventions on pain interference in individuals with spinal cord injury.

METHODS

This systematic review included randomized controlled trials and quasi-experimental (non-randomized) studies which assessed the impact of an intervention on pain interference in individuals with spinal cord injury and neuropathic pain. Articles were identified by searching MEDLINE (1996 to April 11, 2022), EMBASE (1996 to April 11, 2022), PsycInfo (1987 to April, week 2, 2022). Studies were assessed for methodologic quality using a modified GRADE approach and were given quality of evidence (QOE) scores on a 4-point scale ranging from very low to high.

RESULTS

Twenty studies met the inclusion criteria. These studies fell into the following categories: anticonvulsants (n = 2), antidepressants (n = 1), analgesics (n = 1), antispasmodics (n = 1), acupuncture (n = 2), transcranial direct current stimulation (n = 1), active cranial electrotherapy stimulation (n = 2), transcutaneous electrical nerve stimulation (n = 2), repetitive transcranial magnetic stimulation (n = 1), functional electrical stimulation (n = 1), meditation and imagery (n = 1), self-hypnosis and biofeedback (n = 1), and interdisciplinary pain programs (n = 4).

CONCLUSION

When considering studies of moderate to high quality, pregabalin, gabapentin, intrathecal baclofen, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation (in 1 of 2 studies) were shown to have beneficial effects on pain interference. However, due to the low number of high-quality studies further research is required to confirm the efficacy of these interventions prior to recommending their use to reduce pain interference.

Quantification of Needle Angles for Traditional Lumbar Medial Branch Radiofrequency Ablation: An Osteological Study

BACKGROUND

Clinical outcomes following lumbar medial branch radiofrequency ablation (RFA) have been inconsistent. One possible reason is less-than-optimal placement of the electrode along the medial branch at the lateral neck of superior articular process (SAP). Needle angles that define optimal placement (i.e., parallel to the medial branch) may be helpful for consistent technical performance of RFA. Despite its importance, there is a lack of anatomical studies that quantify RFA needle placement angles.

OBJECTIVE

To quantify and compare needle angles to achieve parallel placement along the medial branch as it courses on the middle two-quarters of the lateral neck of the SAP at the L1-L5 vertebrae.

DESIGN

Osteological Study.

METHODS

Ten lumbar vertebral columns were used in this study. Needles were placed along the periosteum of the middle two-quarters of the lateral neck of SAP. Mean needle angles for L1-L5 were quantified and compared using posterior (n = 100) and lateral (n = 100) photographs.

RESULTS

Mean needle angles varied ranging from 29.29 ± 17.82° to 47.22 ± 16.27° lateral to the parasagittal plane (posterior view) and 33.53 ± 10.23° to 49.19 ± 10.69° caudal to the superior vertebral endplate (lateral view). Significant differences in mean angles were found between: L1/L3 (P = .008), L1/L4 (P = .003), and L1/L5 (P = .040) in the posterior view and L1/L3 (P = .042), L1/L4 (P < .001), L1/L5 (P < .001), L2/L4 (P = .004), and L2/L5 (P = .004) in lateral view.

CONCLUSIONS

Variability of needle angles suggest a standard "one-size-fits-all" approach may not be the optimal technique. Future research is necessary to determine optimal patient-specific needle angles from a more detailed and granular analysis of fluoroscopic landmarks.

The potential effects of untreated sleep-related breathing disorders on neuropathic pain, spasticity, and cardiovascular dysfunction following spinal cord injury: A cross-sectional prospective study protocol

INTRODUCTION

Sleep-related breathing disorders (SRBDs), neuropathic pain, spasticity and cardiovascular autonomic dysfunction are common after spinal cord injury (SCI). Prior studies suggest that systemic inflammation following SCI may be implicated in the development of neuropathic pain, spasticity and cardiovascular dysfunction. Given that SRBDs also cause a systemic inflammatory response, we hypothesized that individuals with SCI who develop more severe SRBDs would experience more intense neuropathic pain, more severe spasticity and more significant cardiovascular autonomic dysfunction.

METHODS

This cross-sectional prospective study will explore the previously understudied hypothesis that SRBDs are associated with increased neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in adult individuals with low-cervical/high-thoracic (injury level at C5 to T6), complete/incomplete (ASIA Impairment Scale A, B, C or D) SCI.

DISCUSSION

To our knowledge, no prior study has addressed this clinically relevant question on whether the degree of SRBDs affects the intensity of neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in individuals with SCI. We anticipate that the results of this original study will provide key information for a future clinical trial on the use of continuous positive airway pressure (CPAP) therapy for moderate-to-severe SRBDs, which may better control neuropathic pain, spasticity, and cardiovascular autonomic dysfunction among individuals with SCI.

TRIAL REGISTRATION

The research protocol for this study was registered in the ClinicalTrials.gov website (NCT05687097). https://clinicaltrials.gov/ct2/show/NCT05687097.

Anatomical study of the medial branches of the lumbar dorsal rami: implications for image-guided intervention

INTRODUCTION

Fluoroscopic-guided radiofrequency ablation of the lumbar medial branches is commonly performed to manage chronic low back pain originating from the facet joints. A detailed understanding of the course of medial branches in relation to bony and soft tissue landmarks is paramount to optimizing lumbar denervation procedures, particularly parallel placement of the radiofrequency electrode. The objectives of this study were to investigate the relationship of medial branches to anatomical landmarks and discuss the implications for lumbar denervation.

METHODS

Ten cadaveric specimens were meticulously dissected. The origin, course, and relationship of lumbar medial branches to bony and soft tissue landmarks were documented.

RESULTS

The medial branches followed the lateral neck of superior articular process deep to the intertransversarii mediales muscle at each lumbar vertebral level. In all specimens, the medial branches coursed laterally on the anterior half of the neck and transitioned from parasagittal-to-medial on the posterior half to reach the mamillo-accessory notch. The mamillo-accessory ligament was found to not occlude the nerve on the posterior quarter of the lateral neck but rather at the mamillo-accessory notch located at the posterior margin of the superior articular process.

DISCUSSION

A detailed understanding of the relationship of medial branches to anatomical landmarks is essential to optimizing needle placement for lumbar denervation procedures. The current study suggests that a parasagittal placement, with increased cranial-to-caudal angulation of the electrode, may improve parallel tip alignment with the targeted medial branch and represent a potential alternative to the traditional technique.

Publication Rate of Presentations at a National Physical Medicine and Rehabilitation Scientific Conference From 2009 to 2018

ABSTRACT

Conferences are important platforms for sharing research, but full-text publication is necessary for broader dissemination and impact. Few studies have examined the abstract-to-publication rate for physical medicine and rehabilitation. This study aimed to determine the abstract-to-publication rate of research abstracts presented from 2009-2018 at the Canadian Association of Physical Medicine and Rehabilitation annual scientific meetings. Using the official book of abstracts from 2009 to 2018, year of conference, abstract title, author names, and the affiliation/level of training of the first author were extracted. Systematic searches of abstract key words, authors' names, and the abstract title were performed using PubMed and Google Scholar to determine whether an abstract proceeded to full-text publication; if so, the date and journal of publication were extracted. Of the 524 total abstracts presented at the Canadian Association of Physical Medicine and Rehabilitation from 2009 to 2018, 187 went on to full-text publication for an abstract-to-publication rate of 35.8%. The mean time to full-text publication was 23.4 ± 8.63 mos. The abstract-to-publication rate was 18.6% for medical students, 28.7% for residents, 41.1% for physical medicine and rehabilitation consultants, and 49.4% for nonphysician presenters. This study highlights that low abstract-to-publication rates for novel research presented at the Canadian Association of Physical Medicine and Rehabilitation disproportionately affects trainees. Further research is needed to identify and remedy barriers to publication.

Online psychosocial intervention for persons with spinal cord injury: A meta-analysis

BACKGROUND

Delivery of psychosocial interventions via the Internet has the potential to overcome barriers and increase access; however, effectiveness is yet to be established among those with spinal cord injury (SCI).

METHODS

The objective of this meta-analysis is to evaluate the efficacy of Internet-based psychosocial interventions on the symptoms of anxiety, depression, and pain amongst those with SCI. The databases Medline, PsycInfo, and EMBASE were used to locate studies published between 1990 and December 2020. A study was included if (1) the study involved the application of an online psychosocial intervention; (2) adults with SCI; and (3) reported outcomes on depression and/or anxiety. From each study, participant characteristics and study details were extracted. A standardized mean difference (SMD) ± standard error and 95% confidence interval (CI) was calculated for each outcome of interest and the results were pooled using a fixed-effects model.

RESULTS

The search yielded 920 studies, of which five were included in the final meta-analysis; It was revealed that Internet-based psychosocial interventions had a small effect on reducing overall anxiety (SMD: 0.42 ± 0.09, p < 0.001) and depression (SMD: 0.41 ± 0.09, p < 0.001) symptoms at the end of the study period. Online psychosocial interventions also had a moderate effect in maintaining reduction of anxiety (SMD: 0.50 ± 0.1, p < 0.001) and depressive (SMD: 0.64 ± 0.10, p < 0.001) symptoms at 3-month follow-up.

CONCLUSION

The results of this meta-analysis provide evidence for the use of internet-based psychosocial interventions to manage anxiety and depression symptoms among those with spinal cord injuries.

A pilot living clinical practice guidelines approach was feasible and acceptable to guideline panel members

OBJECTIVES

Clinical practice guidelines (CPGs) help to translate best available evidence into clinical practice but can be challenging to keep current due to their resource intensive nature. A "living" process that is used to continually update CPGs may therefore be of value.

STUDY DESIGN AND SETTING

This pilot study assesses the development of a living CPG protocol based on the CanPainSCI CPG. Two "living CPG" update searches were performed; resource costs and acceptability were assessed by a research team across Australia and Canada RESULTS: Two updates were completed over 3 years. Literature searches and data extraction were completed by trainees on 119 and 58 papers. Eight papers were included and reviewed by 14 expert panel members. Resource usage included a total 43 hours of screening by trainees at $2,356 (USD), 24 hours of expert panel review at $3,141 (USD) and 30 hours of project management at $3,241 (USD). Reviewers were generally satisfied with the process. All reviewers agreed that incorporating a living guidelines approach would be useful.

CONCLUSION

This paper outlines the process of maintaining a CPG through a living guideline process and provides resource costs and acceptability data which may aid stakeholders in the development of future CPGs.

Feasibility of a virtual service delivery model to support physical activity engagement during the COVID-19 pandemic for those with spinal cord injury

BACKGROUND

The current pandemic has reduced access to safe, monitored physical activity (PA) programs for persons with spinal cord injury (SCI). The use of telerehabilitation has the potential for continuing activity engagement without risking virus exposure. The present study evaluates the feasibility and efficacy of an online group-based PA program for persons with SCI.

METHODS

This preliminary pre-post study delivered an online group-based PA program to persons with SCI. The program consisted of 1-hour sessions twice weekly for six weeks. Online PA satisfaction questionnaires were assessed at post-treatment. Psychosocial subscales from the NeuroQOL-SF were assessed.

RESULTS

Participants were adult females between 3 and 32 years post-injury, 1 tetraplegic and 3 paraplegics (n = 4). All participants were highly satisfied with the online instruction, overall content, and videoconferencing platform. Participants stated that the online program was beneficial for their overall physical and psychosocial wellbeing. The program resulted in improvement in anxiety and satisfaction with social roles and activities.

CONCLUSION

The current pilot study demonstrates the acceptability and limited efficacy of an online PA program for those with SCI. The program resulted in improved overall perceived wellbeing and satisfaction with social roles and activities. These results have important implications for the clinical implementation of online PA programs in a hospital and community setting.

A randomised control trial of TeleClinical Care – a smartphone-app based model of care for heart failure and acute coronary syndromes

Background

Acute coronary syndrome (ACS) and heart failure (HF) are frequent causes of hospitalisation and readmissions. A novel smartphone app-based model of care (TeleClinical Care – TCC) was developed to support patients after ACS or HF admission.

Purpose

This randomised control trial aimed to characterise both the intervention and clinical outcomes. The primary endpoint was the incidence of 30-day readmissions. Secondary endpoints included six-month cardiac and all-cause readmissions, mortality, major adverse cardiovascular events (MACE), cardiac rehabilitation (CR) completion, medication adherence, serum low-density lipoprotein (LDL-C), quality of life, blood pressure, body mass index, waist circumference and six-minute walk distance. Additionally, cost-effectiveness and user satisfaction were evaluated.

Methods

Patients were randomised 1:1 to either TCC plus usual care or usual care alone and were followed-up at six months. Intervention arm participants received the TCC app and were asked to use Bluetooth-enabled devices for measuring weight, heart rate, blood pressure and physical activity daily. Readings were automatically transmitted to the patient's smartphone and a secure web-server (KIOLA). Customisable thresholds for each parameter were defined at discharge. Abnormal readings were flagged by email to a monitoring team, who discussed management with the patient's usual healthcare providers. The app also provided educational push notifications.

Results

164 patients from two hospitals in Sydney, Australia were enrolled between February 2019 and March 2020 (TCC n=81, control n=83). Recruitment ceased during the COVID-19 pandemic. The mean age was 61.5 years. 79% of patients were male. The per-patient mean percentage of days with data transmission was 64.2±27.5%. 565 alerts were received, 16% of which resulted in additional investigations, healthcare consultation or a change in management. There was no difference in 30-day readmission rate (11 readmissions in each arm). There was a significant difference in six-month readmissions, favouring the intervention (21 vs. 41 readmissions, HR=0.40, 95% CI 0.16–0.95, P=0.03), driven by a reduction in cardiac readmissions (11 vs. 25, HR=0.51, 95% CI 0.27–0.94, P=0.03). Use of TCC was associated with improved CR completion (39% vs. 18%, P=0.025) and medication adherence (75% vs. 50%, P=0.002). There was no significant difference in mortality, MACE, LDL-C, quality of life or any of the physical parameters. The average user rating was 4.56 out of 5. The study cost EUR 4015 per readmission saved. Upon modelling, it was calculated that if the number of enrolled patients exceeds 243, total expenditure will be overcome by cost savings from reducing readmissions.

Conclusion

The TCC model of care was feasible and safe. In this study, clinical benefits were demonstrated including a reduction in six-month readmissions, improved CR completion and improved medication adherence.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Prince of Wales HospitalPrince of Wales Hospital Foundation Figure 1. TCC interfaceFigure 2. Cumulative readmissions over the course of the trial

A Retrospective Cohort Study of Healthcare Utilization Associated with Paravertebral Blocks for Chronic Pain Management in Ontario

Background: Injections, particularly paravertebral blocks (PVBs), are frequently performed procedures in Ontario, Canada, for the management of chronic pain, despite limited evidence and risk of complications. Aim: This study examines usage patterns of PVBs to evaluate their effects on healthcare utilization and opioid prescribing. Methods: A retrospective cohort study in Ontario using administrative data. Ontario residents receiving their initial PVBs between July 1, 2013 and March 31, 2018 were included. Changes in use of other interventions, physician visits, and opioids were compared to the 12-month periods before and after index PVBs. Data use was authorized under section 45 of Ontario's Personal Health Information Protection Act. Results: 47,723 patients received their initial PVBs in the study period. The rate of index PVBs increased from 1.61 per 10,000 population (2013) to 2.26 per 10,000 (2018). Initial PVBs were performed most commonly by family physicians (N = 25,042), followed by anesthesiologists (N = 14,195). 23,386 patients (49%) received 1 to 9 repeat PVBs in the 12 months after index PVB; 12,474 patients (26.15%) received 10 or more. Use of other nonimage guided interventional pain procedures per patient (mean±SD) increased from 2.19 ± 9.35 to 31.68 ± 52.26 in the year before and after index PVB. Relevant physician visits per patient (mean±SD) also increased from 2.92 ± 3.61 to 9.64 ± 11.77. Mean opioid dosing did not change significantly between the year before and the year after index PVB. Conclusion: PVBs are associated with increases in healthcare utilization and no change in opioid use patterns.

Cannabinoids and an anti-inflammatory diet for the treatment of neuropathic pain after spinal cord injury (The CATNP Study): study protocol for a randomized controlled trial

STUDY DESIGN

Multicenter, randomized, double-blind, placebo controlled, clinical trial.

OBJECTIVE

The objective of this paper is to evaluate the effectiveness of cannabinoids and an anti-inflammatory diet, alone and in combination, for the management of neuropathic pain (NP) after spinal cord injury (SCI).

SETTING

Two Canadian SCI rehabilitation centers.

METHODS

A sample of 144 individuals with SCI will receive either an anti-inflammatory diet, cannabinoids or a placebo for 6 weeks. Following this, a combined effect of these treatments will be evaluated for a further 6 weeks. The primary outcome measure will be the change in NP as assessed by the numeric rating scale (NRS). Secondary outcomes will include changes in inflammation, mood, sleep, spasticity, cost-effectiveness, and function.

CONCLUSION

This study will assess the efficacy of an anti-inflammatory diet and cannabinoids (individually and in combination) for the treatment of NP following SCI. Results may reveal a cost-effective, side-effect free intervention strategy which could be utilized for the long-term management of NP following SCI.

Using medico-legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy

OBJECTIVE

To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement.

DESIGN

Qualitative descriptive study.

SETTING

Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia.

POPULATION

All obstetric claims and incident notifications occurring within the date range were included for analysis.

METHODS

De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified.

MAIN OUTCOME MEASURES

Rate of claims and notifications, relative frequency of issues, a revised taxonomy.

RESULTS

A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented.

CONCLUSIONS

Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement.

TWEETABLE ABSTRACT

New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims.

Retrospective cohort study of healthcare utilization and opioid use following radiofrequency ablation for chronic axial spine pain in Ontario, Canada

BACKGROUND AND OBJECTIVES

Radiofrequency ablation (RFA) is a common treatment modality for chronic axial spine pain. Controversy exists over its effectiveness, and outcomes in a real-world setting have not been evaluated despite increasing use of RFA. This study examined changes in healthcare utilization and opioid use after RFA in Ontario, Canada.

METHODS

This retrospective cohort study was conducted in Ontario using administrative data. Ontario residents receiving their initial RFA between 1 January 2009 and 31 March 2015 were included. Physician visits, spinal injections, and opioid dosing/prescriptions in the 12-month periods before and after RFA were compared.

RESULTS

The study included 4653 patients. The number of RFA procedures significantly increased from 2009 to 2014 (22.5 cases/1 000 000 person-years to 82.5 cases/1 000 000 person-years). 4465 patients had at least one physician visit pre-RFA; there was a significant 23.89% reduction in physician visits post-RFA (pre-RFA: 29 616 visits; post-RFA: 22 542 visits). All reviewed specialties demonstrated a decrease in physician visits post-RF except neurosurgery. 3445 (85.70%) fewer spinal interventions for axial pain (medial/lateral branch blocks, facet/sacroiliac injections) were performed post-RFA. Significantly fewer epidurals were also performed post-RFA. 198 of 1007 patients (19.66%) on the Ontario Drug Benefit who received opioids pre-RFA did not require a postprocedure opioid prescription. Mean opioid dosing was unchanged post-RFA.

CONCLUSIONS

Healthcare utilization was significantly reduced in the 12 months following RFA, and some patients eliminated opioid use. Selection criteria for RFA are not standardized in Ontario, and appropriate use guidelines for spine interventions may improve outcomes and reduce unnecessary procedures.

Unplanned Admission to the Intensive Care Unit in Postoperative Patients—An Indicator of Quality of Anaesthetic Care?

As a clinical indicator, unplanned admission to the Intensive Care Unit from the operating room has been thought to reflect the quality of anaesthesia care intraoperatively. To explore this concept, we examined all such admissions at three hospitals over a three-month period. Cases were classified according to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) classification system and an assessment was made as to whether the admission was inevitable or not. Demographic data were collected as well as co-morbidities, severity of illness, length of stay, discharge functional status and destination.

There were 165 admissions identified: 55.8% were male, the median age was 63.5 years (range 15–90). There were 24 in-hospital deaths: 151 patients suffered serious morbidity or mortality. In 32 patients (19.4%), the morbidity or mortality was considered at least partially anaesthetic-related, and in 20 (12.1 %), under the control of the anaesthetist. There were 28 admissions (17.0%) with a further 9 anaesthetic-related admissions (5.5%) which were considered potentially avoidable. Avoidable anaesthetic-related admissions were due to drug overdosage (5 cases), drug error (1 case), problems relating to preoperative assessment (1 case), aspiration (1 case) and pulmonary oedema (1 case).

These findings suggest that unplanned admission to the Intensive Care Unit from the operating room is not a satisfactory indicator of quality of care by the anaesthesia team. This indicator appears to represent mainly the surgical and medical conditions of the patients, and their complications. Only one in twenty unplanned admissions in this series were potentially avoidable due to complications of the anaesthetic or the postoperative analgesia.

Development of the circumduction metric for identification of cervical motion impairment

Introduction

Chronic neck pain results in considerable personal, clinical, and societal burden. It consistently ranks among the top three pain-related reasons for seeking healthcare. Despite its prevalence, neck pain is difficult to both assess and treat. Quantitative approaches are required since diagnostic imaging techniques rarely provide information on movement-related neck pain, and most common clinical assessment tools are limited to single plane motion measurement.

Methods

In this study, the ability of an inertial measurement unit to document the cervical motion characteristics of 28 people with chronic neck pain and 23 healthy controls was assessed. A total of six circumduction metrics and one neck circumduction trajectory model were proposed as identification metrics.

Results

Five metrics demonstrated significant differences between the two groups. The neck circumduction trajectory model successfully distinguished between the two groups.

Discussion

The evaluation of the proposed metrics provides proof of concept that novel metrics can be captured with relative ease in the clinical setting using an inexpensive wearable sensor headband. The derivation of the proposed model may open new lines of inquiry into the clinical utility of assessing the multiplanar movement of cervical circumduction. The results obtained from this study also provide additional insight for the development of a sensitive, quantifiable and real-world neck evaluation strategies.

Are Comorbid Pain and Depressive Symptoms Associated with Rehabilitation of Individuals with Spinal Cord Injury?

Objective: To examine the difference in functional outcomes and therapy intensity among individuals with spinal cord injury (SCI) with comorbid depression and pain symptoms compared to those without these symptoms. Methods: A retrospective chart review was conducted of 100 patients admitted to a specialized SCI inpatient rehabilitation unit. Standard demographic factors were collected. Patients were divided into 2 groups: those with comorbid depression and pain symptoms and those without. Outcomes were compared between the 2 groups using analysis of covariance (ANCOVA). Age, gender, level of injury, severity of injury, and FIM^® admission were included in the model as covariates. Main outcomes included FIM^® discharge, length of stay (LOS), intensity of therapy (total physical therapy time [PTt] and total occupational therapy time [OTt]), living arrangement, and vocational status. Results: No significant difference was seen between the 2 groups in FIM^® discharge or OTt; however, those in the comorbidity group required significantly greater PTt than those without (p = .002). Those in the comorbid group also spent longer in inpatient rehabilitation (p = .005). The groups did not differ in postdischarge living arrangements or vocational status. Conclusion: Inpatient rehabilitation physical therapy and LOS differ substantially among individuals with comorbid depression and pain symptoms. This comorbidity may have a negative impact on functional recovery such that individuals may require more physical therapy time and longer LOS. This may also point to the increased resources required to manage individuals with SCI and comorbid depression and pain symptoms.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: introduction, methodology and recommendation overview

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to develop the first Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada.

METHODS

The guidelines were developed in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The Working Group developed 12 recommendations for screening and diagnosis, 12 recommendations for treatment and 5 recommendations for models of care. Important clinical considerations accompany each recommendation.

CONCLUSIONS

The Working Group recommendations for the management of neuropathic pain after SCI should be used to inform practice.

Advancing research and clinical care in the management of neuropathic pain after spinal cord injury: Key findings from a Canadian summit

Background: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI.

Aims: A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI.

Methods: In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action.

Results: A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame.

Conclusion: A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.

Antidepressants Are Effective in Decreasing Neuropathic Pain After SCI: A Meta-Analysis

OBJECTIVE

To systematically review and assess the effectiveness and safety of antidepressants for neuropathic pain among individuals with spinal cord injury (SCI).

METHODS

A systematic search was conducted using multiple databases for relevant articles published from 1980 to April 2014. Randomized controlled trials (RCTs) involving antidepressant treatment of neuropathic pain with ≥ 3 individuals and ≥ 50% of study population with SCI were included. Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference, standard error, and 95% confidence interval for primary (pain) and other secondary outcomes was conducted.

RESULTS

Four RCTs met inclusion criteria. Of these, 2 studies assessed amitriptyline, 1 trazadone, and 1 duloxetine among individuals with neuropathic SCI pain. A small effect was seen in the effectiveness of antidepressants in decreasing pain among individuals with SCI (standardized mean difference = 0.34 ± 0.15; 95% CI, 0.05-0.62; P = .02). A number needed to treat of 3.4 for 30% or more pain relief was found by pooling 2 studies. Of these, significantly higher risk of experiencing constipation (risk ratio [RR] = 1.74; 95% CI, 1.09-2.78; P = .02) and dry mouth (RR = 1.39; 95% CI, 1.04-1.85; P = .02) was found amongst individuals receiving antidepressant treatment compared to those in the control group.

CONCLUSIONS

The current meta-analysis demonstrates that antidepressants are effective in reducing neuropathic SCI pain. However, this should be interpreted with caution due to the limited number of studies. Further evaluation of long-term therapeutic options may be required.

Gabapentinoids are effective in decreasing neuropathic pain and other secondary outcomes after spinal cord injury: a meta-analysis

OBJECTIVE

To examine the effectiveness of gabapentin and pregabalin in diminishing neuropathic pain and other secondary conditions in individuals with spinal cord injury (SCI).

DATA SOURCES

A systematic search was conducted using multiple databases for relevant articles published from 1980 to June 2013.

STUDY SELECTION

Controlled and uncontrolled trials involving gabapentin and pregabalin for treatment of neuropathic pain, with ≥3 subjects and ≥50% of study population with SCI, were included.

DATA EXTRACTION

Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference (SMD), SE, and 95% confidence interval (CI) for primary (pain) and secondary outcomes (anxiety, depression, sleep interference) was conducted.

DATA SYNTHESIS

Eight studies met inclusion criteria. There was a significant reduction in the intensity of neuropathic pain at <3 months (SMD=.96±.11; 95% CI, .74-1.19; P<.001) and between 3 and 6 months (SMD=2.80±.18; 95% CI, 2.44-3.16; P<.001). A subanalysis found a significant decrease in pain with gabapentin (SMD=1.20±.16; 95% CI, .88-1.52; P<.001) and with pregabalin (SMD=1.71±.13; 95% CI, 1.458-1.965; P<.001). A significant reduction in other SCI secondary conditions, including sleep interference (SMD=1.46±.12; 95% CI, 1.22-1.71; P<.001), anxiety (SMD=1.05±.12; 95% CI, .81-1.29; P<.001), and depression (SMD=1.22±.13; 95% CI, .967-1.481; P<.001) symptoms, was shown. A significantly higher risk of dizziness (risk ratio [RR]=2.02, P=.02), edema (RR=6.140, P=.04), and somnolence (RR=1.75, P=.01) was observed.

CONCLUSIONS

Gabapentin and pregabalin appear useful for treating pain and other secondary conditions after SCI. Effectiveness comparative to other analgesics has not been studied. Patients need to be monitored closely for side effects.

Anticonvulsant medication use for the management of pain following spinal cord injury: systematic review and effectiveness analysis

STUDY DESIGN

Systematic review and effectiveness analysis.

OBJECTIVES

Assess the effectiveness of anticonvulsants for the management of post spinal cord injury (SCI) neuropathic pain.

SETTING

Studies from multiple countries were included.

METHODS

CINAHL, Cochrane, EMBASE and MEDLINE were searched up to April 2013. Quality assessment was conducted using the Jadad and the Downs and Black tools. Effect sizes and odds ratios were calculated for primary and secondary outcome in the included studies.

RESULTS

Gabapentinoids, valproate, lamotrigine, levetiracetam and carbamazepine were examined in the 13 included studies, ten of which are randomized controlled trials. Large effect size (0.873-3.362) for improvement of pain relief was found in 4 of the 6 studies examining the effectiveness of gabapentin. Pregabalin was shown to have a moderate to large effect (0.695-3.805) on improving neuropathic pain post SCI in 3 studies. Valproate and levetiracetam were not effective in improving neuropathic pain post SCI, while lamotrigine was effective in reducing neuropathic pain amongst persons with incomplete lesions and carbamazepine was found effective for relief of moderate to intense pain.

CONCLUSION

Gabapentin and pregabalin are the two anticonvulsants which have been shown to have some benefit in reducing neuropathic pain.

An administrative data algorithm to identify traumatic spinal cord injured patients: a validation study

OBJECTIVE

To assess the validity of different administrative data sources available for the identification of traumatic spinal cord injured (TSCI) patients.

STUDY DESIGN

Retrospective validation study.

SETTING

Ontario, Canada.

PARTICIPANTS

Adult patients seen in tertiary outpatient spinal cord rehabilitation clinics after 1 April 2002.

OUTCOME MEASURES

Sensitivity, specificity, positive and negative predicative values of diagnostic ICD10 codes from Canadian Institutes of Health Discharge Abstracts (CIHI-DAD), Rehabilitation Coding Groups (RCG) from that National Rehabilitation System (NRS), and spinal cord injury fee codes from the Ontario Healthcare Insurance Plan (OHIP). Secondary outcome was the agreement between actual lesion level and RCG/ICD10 coded lesion level.

RESULTS

The RCG codes in the NRS have high sensitivity (92%, 95% confidence interval (CI): 87-95%) and specificity (97%, 95% CI: 94-99%) for the identification of true TSCI patients, whereas CIHI-DAD ICD10 codes are highly specific (99%, 95% CI: 95-100) and moderately sensitive (76%, 95% CI: 79-87%). OHIP fee codes had poor sensitivity (64%, 95% CI: 57-71%). Agreement between true lesion level and the NRS and CIHI-DAD coding is good (Kappa of 0.65-0.88 and 0.56-0.70, respectively).

CONCLUSION

This study demonstrated that the NRS is able to accurately discriminate between patients with and without a TSCI. A large population of incident and prevalent TSCI patients are identifiable using administrative data.

SPONSORSHIP

This study was funded by a grant from the Division of Urology, Western University.

Neuropathic pain post spinal cord injury part 2: systematic review of dorsal root entry zone procedure

BACKGROUND

Pharmacotherapy may not sufficiently reduce neuropathic pain in many individuals post spinal cord injury (SCI). The use of alternative therapies such as surgery may be effective in reducing neuropathic pain in these individuals. However, because of the invasive nature of surgery, it is important to examine the evidence for use of this treatment.

OBJECTIVE

The purpose of this study was to conduct a systematic review of published literature on the surgical treatment of neuropathic pain after SCI.

METHODS

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles in which surgical treatment of pain after SCI was examined. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a surgical intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention involving the dorsal root entry zone (DREZ) procedure was used to reduce pain. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale.

RESULTS

Eleven studies met the inclusion criteria. One study provided level 2 evidence, and the rest provided level 4 evidence. The DREZ procedure was shown to be more effective for segmental pain than for diffuse pain after SCI. Further, individuals with conus medullaris level injury were found to have a higher level of neuropathic pain relief than those with cervical, thoracic, or cauda equina injury.

CONCLUSIONS

The studies demonstrated that the DREZ procedure may be effective in reducing segmental pain. Hence, DREZ may be important in treatment of neuropathic pain in individuals resistant to less invasive treatments. Because the studies lacked control conditions and examination of long-term effects, there is a need for larger trials with more stringent conditions.

Neuropathic pain post spinal cord injury part 1: systematic review of physical and behavioral treatment

BACKGROUND

Neuropathic pain has various physiologic and psychosocial aspects. Hence, there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury (SCI).

OBJECTIVE

The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI.

METHODS

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing nonpharmacological treatment of pain post SCI. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a treatment or intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention was being studied. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale.

RESULTS

The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI: physical and behavioral treatments. The pooled sample size of all studies included 433 participants. Of the 16 studies included, 7 were level 1, 3 were level 2, and 6 were level 4 studies.

CONCLUSIONS

Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain. Of these interventions, transcranial electrical stimulation had the strongest evidence of reducing pain. Despite a growing body of literature, there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain.

A randomized, placebo-controlled phase 2 study of ganitumab (AMG 479) or conatumumab (AMG 655) in combination with gemcitabine in patients with metastatic pancreatic cancer

BACKGROUND

We evaluated the efficacy and safety of ganitumab (a mAb antagonist of insulin-like growth factor 1 receptor) or conatumumab (a mAb agonist of human death receptor 5) combined with gemcitabine in a randomized phase 2 trial in patients with metastatic pancreatic cancer.

PATIENTS AND METHODS

Patients with a previously untreated metastatic pancreatic adenocarcinoma and an Eastern Cooperative Oncology Group (ECOG) performance status ≤1 were randomized 1 : 1 : 1 to i.v. gemcitabine 1000 mg/m(2) (days 1, 8, and 15 of each 28-day cycle) combined with open-label ganitumab (12 mg/kg every 2 weeks [Q2W]), double-blind conatumumab (10 mg/kg Q2W), or double-blind placebo Q2W. The primary end point was 6-month survival rate. Results In total, 125 patients were randomized. The 6-month survival rates were 57% (95% CI 41-70) in the ganitumab arm, 59% (42-73) in the conatumumab arm, and 50% (33-64) in the placebo arm. The grade ≥3 adverse events in the ganitumab, conatumumab, and placebo arms, respectively, included neutropenia (18/22/13%), thrombocytopenia (15/17/8%), fatigue (13/12/5%), alanine aminotransferase increase (15/5/8%), and hyperglycemia (18/2/3%).

CONCLUSIONS

Ganitumab combined with gemcitabine had tolerable toxicity and showed trends toward an improved 6-month survival rate and overall survival. Additional investigation into this combination is warranted. Conatumumab combined with gemcitabine showed some evidence of activity as assessed by the 6-month survival rate.