Normality Analysis of Numeric Rating Scale Scores in Patients with Chronic Axial Spine Pain Before and After Medial Branch Blocks: a Multicenter Study.

OBJECTIVE: The statistical analysis typically employed to compare pain both before and after interventions assumes scores are normally distributed. The present study evaluates whether Numeric Rating Scale (NRS), specifically the NRS-11, scores are indeed normally distributed in a clinically-relevant cohort of adults with chronic axial spine pain pre- and post-analgesic intervention. METHODS: Retrospective review from four academic medical centers of prospectively collected data from a uniform pain diary administered to consecutive patients after undergoing medial branch blocks. The pain diary assessed NRS-11 scores immediately pre-injection and at 12 different time points post-injection up to 48 hours. D'Agostino-Pearson tests were used to test normality at all time points. RESULTS: One hundred fifty pain diaries were reviewed and despite normally distributed pre-injection NRS-11 scores (K2 = 0.655, p = 0.72), all post-injection NRS-11 data was not normally distributed (K2 = 9.70- 17.62, p = 0.0001-0.008). CONCLUSIONS: Although the results of parametric analyses of NRS-11 scores are commonly reported in pain research, some properties of NRS-11 do not satisfy the assumptions required for these analyses. The data demonstrate non-normal distributions in post-intervention NRS-11 scores, thereby violating a key requisite for parametric analysis. We urge pain researchers to consider appropriate statistical analysis and reporting for non-normally distributed NRS-11 scores to ensure accurate interpretation and communication of these data. Practicing pain physicians should similarly recognize that parametric post-intervention pain score statistics may not accurately describe the data and should expect manuscripts to utilize measures of normality to justify the selected statistical methods.

Challenges and Opportunities in Academic Physiatry: An Environmental Scan.

ABSTRACT: Environmental scans determine trends in an organization's or field's internal and external environment. The results can help shape goals, inform strategic decision making, and direct future actions. The Association of Academic Physiatrists convened a strategic planning group in 2020, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice. This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the Association of Academic Physiatrists and the entire field of academic physiatry (also known as physical medicine and rehabilitation, physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized within the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment. The challenges and opportunities presented here can provide a roadmap for the field to thrive within the complex and evolving healthcare systems in the United States and globally.

A Single-Center Retrospective Analysis Investigating the Effect of Timing of Vertebral Augmentation on Pain Outcomes.

BACKGROUND: Approximately 700,000 individuals experience osteoporotic vertebral compression fractures (OVCF) every year in the United States. Chronic complications from patients and increasing economic burdens continue to be major problems with OVCFs. Multiple treatment options for OVCF are available, including conservative management, surgical intervention, and minimally invasive vertebral augmentation. Prior studies have investigated the utility of vertebral augmentation techniques such as percutaneous vertebroplasty (PVP), balloon vertebroplasty (BVP), and vertebral augmentation with the KivaTM implant on patient mortality with favorable results. The optimal time from OVCF occurrence to vertebral augmentation continues to be a topic of investigation. OBJECTIVES: To further investigate the effect of the timing of vertebral augmentation on pain outcomes. STUDY DESIGN: A retrospective cohort chart review study. SETTING: A single academic center in Albuquerque, New Mexico. METHODS: One hundred twenty-six consecutive patient encounters with OVCF diagnosed on imaging and treated with PVP, BVP, or vertebral augmentation with a KivaTM implant between 01/01/2004 and 11/28/2016 were analyzed. The time between fracture and intervention was categorized into < 6 weeks, 6-12 weeks, and >= 12 weeks. Pain scores were measured before and after treatment using the numeric pain rating scale. Statistical analysis using Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were used as appropriate, and effect sizes were described with the Hodges-Lehmann estimates of difference. RESULTS: The 3 vertebral augmentation procedures compared in this study did not demonstrate statistically significant differences in pain score reduction (P = 0.949). The < 12 weeks group had a median and interquartile range (IQR) pain improvement of 3 (IQR 1,6) versus 1 (IQR 0,4) in the >= 12 weeks group (P = 0.018). Further analysis showed that the median and IQR pain improvement for the < 6 weeks group was 3 (IQR 1,7), for the 6-12 weeks group was 3 (IQR 1,4), and for the >= 12 weeks group was 1 (IQR 0,4). The overall effect of the time category on pain improvement was statistically significant for these groups (P = 0.040). Comparisons between groups only showed differences between the < 6 weeks and >= 12 weeks groups (P = 0.013), with an estimated median difference of 2 (95% CI 0,3). There was no statistically significant relationship between fill percentage and pain relief (P = 0.291). LIMITATIONS: This is a retrospective cohort study from a single academic center with a limited sample size that lacked a control group and procedural blinding. There was also substantial heterogeneity among patients, fractures, operators, and techniques. Pain relief outcomes are subjective and can be biased by patients as well as physician reporting. CONCLUSIONS: Early intervention (< 12 weeks) with vertebral augmentation in patients with OVCF is associated with improved pain scores when compared to later intervention (> 12 weeks). Very early intervention (< 6 weeks) confers a greater advantage when compared to later intervention (> 12 weeks).

Free-standing acute inpatient rehabilitation hospital enhanced practices and policies in response to the COVID-19 outbreak.

This special report was developed to communicate policy and procedures for free-standing acute inpatient rehabilitation hospitals (AIRHs) to protect patients and healthcare personnel and to prevent further spread of severe acute respiratory syndrome coronavirus 2. The recommended policies were developed in conjunction with the New Mexico Department of Health and hospital leadership. As we attain additional knowledge and experience during this pandemic, suggestions of best practice will continue to evolve for AIRHs. The authors encourage readers to work with local regulatory officials to ensure regulatory compliance as well as respect of the availability of local resources.

Using Analgesics for Emotional Modulation is Associated With Increased Distress, Depression, and Risk of Opioid and Alcohol Misuse: Initial Evaluation and Component Analysis of the Reasons for Analgesic Use Measure (RAUM).

OBJECTIVES: It is important to identify aspects of analgesic use that are associated with harm in chronic pain. Historically, the focus has been patterns of use (eg, overuse). This study evaluated another aspect of use-rather than evaluating how analgesics were being used, the primary interest was in why they were being used. METHODS: In total, 334 analgesic using individuals with chronic pain responded to a pool of items assessing reasons for analgesic use. Measures of pain intensity, distress, depression, and opioid and alcohol misuse were also completed. RESULTS: Exploratory factor analyses indicated 3 overarching reasons for use, including taking analgesics: (1) for pain reduction/functional improvement; (2) for emotional modulation/sedation; and (3) to be compliant with prescriber instructions. Correlation and regression analyses indicated that the second factor had the strongest relations with the other measures used, such that greater endorsement of analgesic use for emotional modulation was associated with greater distress, depression, and opioid and alcohol misuse. Using analgesics for pain reduction/functional improvement was associated with greater pain-related distress and depression. Using analgesics to be compliant was not associated with any measure. This pattern of results was generally replicated when a subsample of 131 individuals taking opioids was examined. DISCUSSION: Results support the utility of examining reasons for analgesic use; use to achieve emotional modulation/sedation may be particularly associated with risk. The data also provide support for the questionnaire developed, the Reasons for Analgesic Use Measure.

Signs and Symptoms of Myofascial Pain: An International Survey of Pain Management Providers and Proposed Preliminary Set of Diagnostic Criteria.

OBJECTIVE: Myofascial Pain Syndrome (MPS) is highly prevalent in pain medicine, yet there is no "gold standard" or set of validated diagnostic criteria for clinical or research use. A survey collected clinician perspectives on MPS to foster the development of a formal case definition for empirical validation. DESIGN: International survey. METHODS: Clinician members of the International Association for the Study of Pain and the American Academy of Pain Medicine received a survey of the symptoms and signs of MPS and expected response to treatment. Write-in fields were available for each category and to suggest relevant diagnostic studies. RESULTS: Two hundred fourteen responses were received from 4,143 surveys mailed. The most essential components of MPS were tender spots that recreate symptoms when palpated. MPS was also associated with muscle stiffness, decreased range of motion of the affected joints, worsening symptoms with stress, palpable taut band or tender nodule, and referred pain with palpation of the tender spot. Diagnostic studies are reported to be useful for ruling out other pathology, but not to confirm the presence of the condition. CONCLUSIONS: These results were used to propose a set of preliminary diagnostic criteria; expert consensus for case definition and subsequent empirical validation are required for standardization in research and clinical management of MPS.

Sodium-ion binding to DNA: detection by ultrafast time-resolved stokes-shift spectroscopy.

The nature of the counterion is shown to have a pronounced effect on the apparent dynamic polarity in the interior of DNA. Time-resolved Stokes-shift measurements in the 80 ps to 40 ns time range were made on a polarity-sensitive fluorophore (coumarin 102) that replaces a base pair in an oligonucleotide. With sodium counterions, the emission spectrum narrows with time, whereas with tetrabutylammonium counterions, it does not. Our interpretation is that a subpopulation of helices have sodium cations bound in a fashion that slows the normal dynamics.

Diagnosis of sporotrichosis in a donkey using direct fluorescein-labeled antibody testing.

A 4-year-old female donkey residing in an open field in Indiana was admitted for evaluation of facial lesions of 2 years duration. Cytologic and histologic examination of exudate and tissue from the lesions revealed a pyogranulomatous inflammatory reaction with numerous yeasts. Sporothrix schenckii was suspected to be the infectious agent; however, multiple culture attempts did not provide positive identification of the organism. Serologic examination supported infection with S. schenckii. A specific direct immunofluorescent antibody test performed on paraffin-embedded tissue sections confirmed the organism as S. schenckii. Clinical signs resolved after appropriate iodide therapy.

Results of renal ultrasonography performed before and during administration of saline (0.9% NaCl) solution to induce diuresis in dogs without evidence of renal disease.

OBJECTIVE: To evaluate the effect of saline (0.9% NaCl) solution administered IV to induce diuresis on 15 dimensional variables of the kidneys, size of renal pelvis, and diameter of the cranial part of the ureters. ANIMALS: 25 dogs without evidence of renal disease that were undergoing chemotherapy for various neoplasms. PROCEDURE: The kidneys, cranial aspect of the ureters, and trigone area of the urinary bladder of each dog were examined ultrasonographically before and during IV administration of saline solution (2.7 to 18.8 ml/kg of body weight/h). RESULTS: Ultrasonography revealed unilateral and bilateral pyelectasis during diuresis in 16 of 23 (70%) dogs but unilateral pyelectasis in only 1 dog before diuresis. Unilateral pyelectasis during diuresis was observed in 11 of 16 (69%) dogs. Pyelectasis during diuresis was categorized as slight in 15 of 21 (71%) kidneys. Degree of pyelectasis during diuresis was not identical in both kidneys of 13 of 16 (81 %) dogs. Diuresis did not induce ureterectasis, and it did not cause changes in 15 dimensional variables of the kidneys. CONCLUSIONS: In nonsedated, nonazotemic dogs, IV administration of saline solution to induce diuresis may cause slight pyelectasis without evidence of ureterectasis. CLINICAL RELEVANCE: When dilatation of the cranial part of the ureter is > 2 mm at the same time that ipsilateral pyelectasis is detected during ultrasonographic examination of the urinary tract system of a nonsedated, nonazotemic dog receiving IV administration of saline solution to induce diuresis, additional examinations are recommended to determine the possibility of early obstructive nephropathy or pyelonephritis.

Cardiorespiratory and anesthetic effects of propofol and thiopental in dogs.

OBJECTIVE: To compare cardiorespiratory and anesthesia effects of IV administered propofol and thiopental in dogs. ANIMALS: 6 healthy mixed-breed dogs. PROCEDURE: Each dog was anesthetized with isoflurane, then a thermistor catheter was inserted in the pulmonary artery. After a minimum of 2.5 hours of recovery, a catheter was placed in a cephalic vein for administration of lactated Ringer's solution and drugs. Propofol (8 mg/kg of body weight) or thiopental (19.4 mg/kg) was administered to each dog in a randomized crossover design study. All dogs were intubated and allowed to breathe 100% oxygen spontaneously. Heart rate and rhythm; systolic, diastolic, and mean arterial blood pressures; respiratory rate; end-tidal carbon dioxide concentration; tidal volume; and reflexes (toe web pinch, palpebral response, and jaw tone) were measured before and every 2 minutes for the first 10 minutes, then at 15, 30, and 60 minutes after drug administration. Cardiac output was determined at 0, 2, 6, 10, 15, 30, and 60 minutes, and blood samples were collected at 0, 2, 10, and 30 minutes. Time to endotracheal extubation, head lift, and ability to sit sternally and walk unaided were recorded. RESULTS: 3 of 6 dogs in each group were apneic after drug administration. Reflexes were decreased similarly for both anesthetic agents, but were not completely lost. Time to sternal position and walking unaided were significantly shorter in response to propofol. CONCLUSION: Anesthesia was rapid; however, respiratory depression and apnea were major adverse effects associated with propofol and thiopental. Propofol has the advantage of inducing rapid, coordinated anesthesia recovery.

Diagnostic imaging of the feline lower urinary tract.

Survey radiography, double contrast cystography, and antegrade urethrocystography are valuable imaging tools available to the clinician for evaluation of cats with lower urinary tract disease. However, to be cost effective during patient evaluation, diagnostic radiographic procedures should be used only when needed. An algorithm is presented that describes when radiographic imaging techniques may be most cost effective in providing useful information during the clinical workup of cats with lower urinary tract disease.

Evaluation of activity of putative superoxide dismutase mimics. Direct analysis by stopped-flow kinetics.

By stopped-flow kinetic analysis, we have directly evaluated the superoxide dismutase (SOD) activity of a number of organic nitroxides and iron- and manganese-based complexes that have been attributed with having SOD activity based upon competition experiments with cytochrome c. In 60 mM HEPES buffer, pH 8.1, or 50 mM potassium phosphate buffer, pH 7.8, Mn(II) and manganese complexes of desferal had no detectable SOD activity by stopped-flow analysis (catalytic rate constant (kcat) < 10(5.5) M-1 s-1), whereas Mn(II) and manganese complexes of desferal inhibited the reduction of cytochrome c by superoxide generated by the xanthine/xanthine oxidase system. Fe(II)-N,N,N',N'-tetrakis(2-pyridylmethyl)ethylenediamine (FeTPEN) was eight times more active than Fe(III)-tris[N-(2-pyridylmethyl)-2-aminoethyl]amine(Fe-TPAA) in the cytochrome c assay, but only FeTPAA catalyzed the first-order decay of superoxide (kcat = 2.15 x 10(6) M-1 s-1) by stopped-flow. Fe(III)-tetrakis(4-N-methylpyridyl)porphine (FeTMPP) was active at low micromolar concentrations in both the cytochrome c and stopped-flow assays. At high micromolar concentrations, the organic nitroxides 2,2,6,6-tetramethylpiperidin-1-yloxy (TEMPO) and 4-hydroxy-2,2,6,6-tetramethylpiperidin-1-yloxy (TEMPOL) were inhibitory in the cytochrome c assay, but showed no detectable SOD activity by stopped-flow. None of the tested compounds inhibited xanthine oxidase activity as shown by the measurement of urate production. Under the conditions of the cytochrome c assay, FeTPEN, TEMPO, and TEMPOL oxidized reduced cytochrome c which rationalizes the false positives for these compounds in this assay. The inhibitory activities of Mn(II) and the manganese desferal complexes in the cytochrome c assay appear to be due to a stoichiometric, not catalytic, reaction with superoxide as catalytic amounts of these agents do not induce a first-order decay of superoxide as shown by stopped-flow.

Stopped-flow kinetic analysis for monitoring superoxide decay in aqueous systems.

We have utilized a commercially available, computer-driven stopped-flow spectrophotometer to rapidly measure the self-dismutation or catalyzed decay of superoxide in aqueous buffers. In the self-dismutation assay, a dimethyl sulfoxide solution of superoxide is mixed in less than 2 ms with an aqueous buffer. The decay of superoxide is monitored directly by its absorbance at 245 nm and the data is processed by computer. By careful purification of the water and the use of metal-free buffers, a decay of superoxide that fits second-order kinetics is obtained without using metal ion chelators in the buffer. The second-order rate constant for superoxide decreased with increasing pH and decreased by a factor of 3.3 by using D2O in place of H2O in the buffer. The rapid mixing time makes it possible to determine rate constants for active superoxide dismutase catalysts at a pH as low as 7. A first-order decay of superoxide is obtained when the aqueous buffer contains bovine Cu/Zn superoxide dismutase or aquo copper(II), which are known catalysts of superoxide dismutation. The rate of superoxide decay was established to be first-order in catalyst. The catalytic rate constant for bovine Cu/Zn superoxide dismutase was determined to be 2.3 x 10(9) M-1 s-1 in H2O and D2O-based buffers and was independent of pH over the range 7-9. Aquo copper(II) gave a catalytic rate constant of 1.2 x 10(8) M-1 s-1, but was ineffective in the presence of EDTA. The catalytic rate constants obtained by stopped-flow kinetics are in excellent agreement with studies carried out by the direct method of pulse radiolysis.

Somatotopically inappropriate projections from thalamocortical neurons to the SI cortex of the cat demonstrated by the use of intracortical microstimulation.

Single thalamocortical neurons with receptive fields on the toes were antidromically activated by the passage of 300-microseconds, 0.5- to 10-microA pulses through glass micropipette electrodes placed within somatotopically identified regions of the digit representation of the cat first somatosensory (SI) cortex. The somatotopy of the cortex was determined using recordings from single cortical neurons (see "Methods"), and the positions of the all tracks were marked on an enlarged photograph of the postcruciate cortex. In two of the three protocols, a very precise map of the boundary between two adjacent toes was produced prior to attempting intracortical microstimulation. Slopes of the threshold-distance curves at the sites of the lowest recorded thresholds were on the order of 0.8 microA/10 micron. This value, together with information on the anatomy of the cortical arborizations of thalamocortical neurons (Landry and Deschenes, 1981), suggested that currents of 2 and 5 microA would not activate the cortical processes of thalamocortical neurons at distances greater than 50 and 90 microns, respectively. With currents below 5 microA, thalamocortical neurons could be antidromically activated at a number of sites at depths between 340 and 930 microns (layer IV and upper layer III) and between 1,050 and 1,460 microns (layer VI). A total of 13 thalamocortical neurons could be antidromically activated using current pulses of between 0.8 and 5.0 microA, from within tracks at tangential distances of 250-830 microns from the nearest track through the somatotopically appropriate region. Within somatotopically inappropriate regions, cortical neurons frequently had receptive fields on a toe adjacent to that bearing the receptive field of the thalamic neuron(s) under study. The possible relationship of somatotopically inappropriate projections to the reorganization of cortical somatotopy following digit amputation, paw amputation, and nerve section is discussed.