Pilot Study on Therapeutic Horticulture for Chronic Low Back Pain: A Mixed Methods Study.

Background: Chronic low back pain (LBP) is common and associated with disability worldwide. Therapists trained in Therapeutic Horticulture (TH) use gardening activities and proximity to nature for therapy and rehabilitation. Patients seeking care for LBP would benefit physically and psychologically from participating in TH. Primary study objectives: The first aim of this study was to determine if and which patients who were receiving care for chronic LBP were interested in TH to help manage their pain. The second aim of the project was to quantify changes in LBP, functional tasks and anxiety upon completion of a TH session in patients with LBP. Methods/Design: This was a 2-part study with a mixed methods design: the cross-sectional survey Group and the pilot experimental Group. The Cross-sectional Survey component comprised a total of 170 patients; age 55.9±17.3 years; 58% women. The Pilot Experimental component comprised a total of 9 patients; age 48±14.7 years; 78% women. Participants Cross-sectional component: Patients receiving medical care for LBP with or without additional joint pain sites (n=170; age 55.9 ± 17.3 years; 58% women. Participants Pilot experimental component: A total of 9 patients (7 women); mean age 48 ± 14.7 years and mean duration of back pain 12.6 ± 8.1 years. Setting: Patients were receiving medical care at the University of Florida Health Comprehensive Spine Center in the United States, in the tertiary care health system. Intervention: 1-hour TH session that involved trained therapists using propagating and harvesting herbs planted at various heights in an outdoor setting for therapy and rehabilitation. Primary outcome measures: A therapeutic horticulture interest survey, PROMIS Pain Interference and Physical Function scores, functional tests (timed-get-up-and-go [TUG], spine range of motion), Roland Morris Disability Questionnaire (RMDQ), 11-point Numerical Pain Rating Scale (NRSpain), 10-item PROMIS Global Health Questionnaire, Tampa Scale of Kinesiophobia-11 and patient enjoyment. Results: Cross-sectional survey component: A total of 2% of patients had not previously heard of TH and 68% were interested in learning more about it. Patients who expressed interest in TH reported a higher level of agreement that TH could improve mood, improve muscle strength, lower stress level, increase movement and enable patients to perform self-care activities with less pain (all P < .001). PROMIS Pain Interference and Physical Function scores did not differ by interest in TH (P > .05). Pilot Experimental component: In the pilot session, 44% reported using pain medication to manage their low back pain and 66% believed gardening could provide pain relief. Improvements were observed in anxiety (55.3%; P =.017), spine flexion (31.4%; P =.003) and spine rotation to the left (26.7%; P =.005). All participants believed that gardening improved overall health and spine motion while reducing low back pain. All patients reported having gardening experience at home and none had TH experience. Conclusion: Patients presenting to an outpatient spine clinic may be receptive to trying TH in conjunction with or in place of conventional medicine to promote health and well-being. The pilot experimental group data suggested that acute TH is enjoyable and may confer the benefits of reducing anxiety and improving spine motion. Future larger studies could use different dose response approaches, explore different TH activity types and involve participants from different geographic locations while controlling for LBP history and psychological status.

Considerations beyond spine pain: do different co-occurring lower body joint pains differentially influence physical function and quality of life ratings?

BACKGROUND: Patients seeking medical care for back pain often have coexisting painful joints and the effects of different combinations and number of coexisting pain sites (hip, knee, foot/ankle) to back pain on physical function domains and quality of life rating are not yet established. The purpose of this study was to determine the differences in functional outcomes and QOL among individuals with back pain who have concurrent additional pain sites or no pain sites. METHODS: Data from the Osteoarthritis Initiative (OAI) cohort were used for this cross-sectional analysis. Men and women aged 45-79 years with back pain were binned into nine groups by presence or not of coexisting hip, knee, ankle/foot pain and combinations of these sites (N = 1,642). Healthy controls reported no joint pain. Main outcomes included Knee Injury and Osteoarthritis Outcome score (KOOS; quality of life and function-sports-and-recreation), Western Ontario McMaster Universities Osteoarthritis Index (WOMAC; Activities of Daily Living, Pain), Medical Outcomes Short Form-12 (SF-12) Physical Component score, and self-reported function in last 7-30 days (lifting 25-pound objects, housework). 20-m and 400-m walk times and gait speed and repeated chair rise test times were collected. RESULTS: Compared to back pain alone, pain at all five sites was associated with 39%-86% worse KOOS, WOMAC, and SF-12 scores (p < .0001). Back-Hip and Back-Knee did not produce worse scores than Back pain alone, but Back-Hip-Knee and Back-Knee-Ankle/Foot did. The 20-m, 400-m walk, and repeated chair times were worse among individuals with pain at all five sites. Additional hip and knee sites to back pain, but not ankle/foot, worsened performance-based walk times and chair rise scores. CONCLUSIONS: The number and type of coexistent lower body musculoskeletal pain among patients with back pain may be associated with perceived and performance-based assessments. Management plans that efficiently simultaneously address back and additional coexistent pain sites may maximize treatment functional benefits, address patient functional goals in life and mitigate disability.

Aromatherapy for Procedural Anxiety in Pain Management and Interventional Spine Procedures: A Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate a nonsedating agent, lavender aromatherapy, to reduce anxiety before interventional spinal procedures. DESIGN: In this prospective, single-blind study performed at a tertiary care center for an academic institution, 144 patients undergoing spinal procedures (epidural steroid injection, medial branch block, or radiofrequency ablation) were randomized into two groups of 72 patients. The experimental group was exposed to a tablet formulation of lavender aromatherapy, while the control group was exposed to tablets devoid of any scent. The exposure duration for each group was 5 mins. The primary outcome measurement was patients' anxiety state before the spinal procedure using the six-item State-Trait Anxiety Inventory. Secondary outcomes quantified the rate of vasovagal events and aborted procedures because of patient intolerance. RESULTS: Compared with the control group, the posttreatment anxiety score of those exposed to lavender aromatherapy revealed a statistically significant difference as measured by the six-item State-Trait Anxiety Inventory (12.15 ± 2.67 and 10.67 ± 2.81, P < 0.05). Within group, the experimental group's anxiety level decreased from 12.26 ± 2.75 to 10.67 ± 2.81 (P < 0.05). There were two vasovagal episodes and one aborted procedure in the control group, whereas there was one vasovagal episode and no aborted procedures in the aromatherapy group. CONCLUSIONS: Lavender-based aromatherapy is effective in reducing preprocedural anxiety before interventional spine procedures for pain management.

Cannabis Use and Low-Back Pain: A Systematic Review.

Introduction: The potential use of cannabis and cannabinoid products for the treatment of low-back pain is an important area for investigation. As one of the leading reasons to visit a primary care provider, low-back pain results in a significant burden of disease in both the United States' economic and health care systems. Given the current opioid epidemic, it is important to seek novel analgesics and understand their efficacy for myriad pain conditions, including low-back pain. Materials and Methods: A systematic review was performed using multiple online databases to assess the association of cannabis use and low-back pain in the literature. Results: A total of 124 articles were produced via our search methods, 73 abstracts in total were screened, 16 articles underwent full-text review, and 6 articles were included in qualitative synthesis. Discussion: This systematic literature review reveals a lack of primary research investigating cannabis as a potential treatment of low-back pain and highlights the need for further investigation with well-designed clinical trials. There remain substantial political and legal barriers to performing such research. Conclusion: Although there is a considerable body of work on the usage of cannabinoid products for many medical conditions, including the treatment of chronic pain, more directed clinical research into their utility as an analgesic for low-back pain and related symptoms needs to be addressed.

Advanced Progression of Scoliosis After Intrathecal Baclofen in an Adult With Stiff Person Syndrome: A Case Report.

Stiff person syndrome is a neuroimmunological disorder characterized by progressive muscular rigidity and spasms that affect axial/limb muscles, resulting in severe pain and functional limitations. When refractory to conservative treatments, intrathecal baclofen is a viable option to treat the increased tone. Intrathecal baclofen has been shown to accelerate underlying neuromuscular scoliosis in the pediatric population with cerebral palsy. This adverse effect has never been reported in adults with stiff person syndrome. We report a case of an adult with stiff person syndrome and underlying scoliosis who experienced accelerated progression of scoliosis after initiation of intrathecal baclofen, subsequently requiring neurosurgical intervention.

The Impact of Local Steroid Administration on the Incidence of Neuritis following Lumbar Facet Radiofrequency Neurotomy.

BACKGROUND: Pain arising from the lumbar facet joints is a common cause of axial back pain in adults. Radiofrequency neurotomy (RFN) of the medial branches of the spinal dorsal rami has been used as a treatment option. The most common side effect is transient, localized, burning, neuritic-type pain, termed post-neurotomy neuritis (PNN). Corticosteroids have been administered through the radiofrequency cannula after neurotomy to prevent PNN, but no study has examined the effects of this on PNN. OBJECTIVES: We investigated the incidence of PNN in patients who received corticosteroids after RFN and in those patients who did not receive corticosteroids. STUDY DESIGN: Retrospective evaluation. SETTING: Single-site interventional pain management practice in an urban tertiary academic medical center. METHODS: One hundred and sixty-four patients were included in this study and were categorized into non-steroid (n = 87) and steroid (n = 77) groups. Patient's age, gender, body mass index (BMI), laterality of procedure, use of neuropathic pain medications, baseline pain, and duration of pain were all recorded. PNN was determined if the patient self-reported transient burning or neuropathic pain at the site prior to or at the 6-week routine follow-up encounter. RESULTS: There was no significant difference in demographic characteristics between the 2 groups in age, gender, baseline pain, and duration of pain. The proportion of patients in the steroid treated group with PNN was 5 out of 77 (6.4%) and the non-steroid group was 6 out of 87 (6.9%). There was no statistically significant difference between the groups. There was no statistically significant difference in the incidence in neuritis between individuals taking neuropathic agents and individuals not taking neuropathic agents. LIMITATIONS: This study has several limitations including small sample size, patients' self-reported neuropathic symptoms, and inability to draw strong conclusions due to the retrospective study design. A single interventionalist performed all the procedures in this retrospective study and variations in technique amongst others are inevitable. CONCLUSION: Administration of steroids after RFN does not reduce the incidence of post-neurotomy neuritis. Concurrently administering neuropathic medications does not protect against neuritis. KEY WORDS: Radiofrequency neurotomy, radiofrequency ablation, neuritis, corticosteroid, lumbar facet pain, post neurotomy neuritis.

Clinical interpretation of opioid tolerance versus opioid-induced hyperalgesia.

Opioid analgesics are commonly used to manage moderate to severe pain. However, the long-term use of opioids could lead to opioid tolerance (OT) and opioid-induced hyperalgesia (OIH). Distinguishing OIH from OT would impact the practice of opioid therapy because opioid dose adjustment may differentially influence OT and OIH. Currently, there are no standard criteria of OT versus OIH causing considerable ambiguity in clinical interpretation and management of these conditions. The authors designed a practitioner-based survey consisting of 20 targeted questions. Answering these questions would require responders' actual clinical experiences with opioid therapy. The survey was conducted between 2011 and 2012 through direct mails or e-mails to 1,408 physicians who are currently practicing in the United States. The authors find that certain clinical characteristics (eg, increased pain despite opioid dose escalation) are often used by practitioners to make differential diagnosis of OT and OIH despite some overlap in their clinical presentation. A key difference in clinical outcome is that OT and OIH could be improved and exacerbated by opioid dose escalation, respectively. Our survey results revealed a significant knowledge gap in some responders regarding differential diagnosis and management of OT and OIH. The results also identified several issues, such as opioid dose adjustment and clinical comorbidities related to OT and OIH, which require future patient-based studies.

Clinical experience using the Mann assessment of swallowing ability for identification of patients at risk for aspiration in a mixed-disease population.

PURPOSE: To determine the clinical performance characteristics of the Mann Assessment of Swallowing Ability (MASA) for predicting aspiration (determined by videofluoroscopic swallowing study [VFSS]) in a mixed population. METHOD: We selected 133 cases clinically evaluated using MASA and VFSS from January through June 2007. Ordinal risk rating (ORR) and total numeric score (TNS) were evaluated as predictors of aspiration on VFSS. To account for missing items, the maximum possible score was determined and a weighted percentage score calculated for each patient. We used receiver operating characteristic (ROC) analysis to compare the sensitivity and specificity of ORR and TNS for predicting aspiration. RESULTS: VFSS identified 51 (38.4%) aspirators, while ORR identified 54 (40.6%) as probable or definite aspiration and TNS 19 (14.3%) as moderate to severe aspiration risk. ROC analysis demonstrated an area under the curve of 0.74, 95% CI [0.66, 0.82], for ORR and 0.51, 95% CI [0.41, 0.61], for TNS. These ROC scores suggest that the MASA ORR is better at predicting aspiration on VFSS than the numeric score. CONCLUSION: In this sample, the subjective ORR had good predictive ability, while the percentage TNS failed to predict aspiration on VFSS. The MASA ORR assessment was a better predictor for a patient's aspiration risk in this population.

Zygomycosis in children: a systematic review and analysis of reported cases.

BACKGROUND: Zygomycosis has emerged as an increasingly important infection with a high mortality especially in immunocompromised patients. No comprehensive analysis of pediatric zygomycosis cases has been published to date. METHODS: We used a PUBMED search for English publications of pediatric (0-18 years) zygomycosis cases and references from major books as well as single case reports or case series. Individual references were reviewed for additional cases. Data were entered into Filemaker-pro database and analyzed by logistic regression analysis. RESULTS: One hundred fifty-seven cases (64% male) were found with median age 5 years (range, 0.16-13). Underlying conditions included neutropenia (18%), prematurity (17%), diabetes mellitus (15%), ketoacidosis (10%), and no apparent underlying condition (14%). The most common patterns of zygomycosis were cutaneous (27%), gastrointestinal (21%), rhinocerebral (18%), and pulmonary (16%). Among 77 culture-confirmed cases, Rhizopus spp. (44%) and Mucor spp. (15%) were most commonly identified. Of 81 patients who were given antifungal therapy, 73% received an amphotericin B formulation only. The remaining patients received mostly amphotericin B in combination with other antifungal agents. Mortality in patients without antifungal therapy was higher than in those with therapy (88% versus 36%, P < 0.0001). Ninety-two (59%) patients underwent surgery. Cerebral, gastrointestinal, disseminated and cutaneous zygomycosis were associated with mortality rates of 100, 100, 88, and 0%, respectively. Independent risk factors for death were disseminated infection (OR: 7.18; 95% CI: 3.02-36.59) and age <1 year (OR: 3.85; 95% CI: 1.05-7.43). Antifungal therapy and particularly surgery reduced risk of death by 92% (OR: 0.07; 95% CI: 0.04-0.25) and 84% (OR: 0.16; 95% CI: 0.09-0.61), respectively. CONCLUSIONS: Zygomycosis is a life-threatening infection in children with neutropenia, diabetes mellitus, and prematurity as common predisposing factors, and there is high mortality in untreated disease, disseminated infection, and age <1 year. Amphotericin B and surgery significantly improve outcome.

Epidemiology and outcome of zygomycosis: a review of 929 reported cases.

BACKGROUND: Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease. METHODS: We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described. RESULTS: The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively). CONCLUSIONS: Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.