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ANALGESIC EFFECT OF CONSEQUENT USE OF PULSATIVE MAGNETIC FIELD AND ANESTHESIN PHONOPHORESIS IN THE PATIENTS WITH NEUROLOGIC SYNDROMES OF LUMBAR OSTEOCHONDROSIS

A.V. Musayev*. Res. Inst. ofMed. Rehab, and Natural Therapy Factors, 3, Khatai St., 370008, Baku, Azerbaijan

Aim of Investigation: To develop the methods of analgesic treatment of pain in the patients with lumbar osteochondrosis with consequent use ofpulsative magnetic field (PMF) and anesthesin phonophoresis (AP).

Methods: The patients underwent a treatment using PMF and AP. Clinico-neurologic and electroneuromyographic studies have been performed.

Results: Positive clinical effect of only PMF use showed 44% of patients, PA - 45% while their consequent use - 69% of patients. Electroneuromyographic study showed the reduction of impulse conduction velocity in peripheral nerve and the reduction of irritability of spinal alpha motor neurons. After the treatment the patients developed the enhancement of impulse conduction velocity and the increase of alpha motor neuron irritability that was more marked in consequent use of PMF and AP.

Conclusion: We feel that above treatment blocks a spread of painful impulse on the side of affected vertebra] segment and thereby has analgesic effect.

REPEATABILITY OF PAIN DRAWINGS IN LOW BACK PAIN PATIENTS

Donna D. Ohnmeiss. Texas Back Inst Research Foundation and the Texas Health Research Inst; Piano, Texas, USA; Dept. of Rehab. Med., Karolinska Inst; Stockholm, Sweden

Aim of Investigation: To determine the repeatability of low back pain patients in completing pain drawings.

Methods: During the first clinic visit, all patients complete a pain drawing. Drawings were collected on a second occasions from 75 patients undergoing preoperative assessment. Included on the drawing were symbols to indicate aching, numbness, pins and needles, burning, and stabbing sensations. To address the possibility of changes in pain location between the two evaluations, a questionnaire asking if there had been any change in pain location since the first clinic visit (date of the first drawing) was included. Only patients who responded "no change in pain location" were included in the repeatability study (45 patients: 24 males, 21 females; mean age 40.6 yrs; mean symptom duration 24.1 mo). The mean duration between the two drawings was 244.2 days (range 26 - 1197 days). The drawings were scored using methods described in the literature: penalty point system (Ransford), visual inspection (Uden), body region (Margolis), and grid (Gatchel). Also, the number of each symbol used to indicate various sensations was recorded.

Results: The rate of agreement between the first and second drawings based on the penalty point system was 86.7% (kappa value 0.588). For the visual inspection method, the rate of agreement was 93.3% (kappa value 0.630). For the Margolis body region method, the average rate of agreement for reporting pain in the same specific regions was 82.3%. The rate of agreement did not vary significantly with the length of time between drawings. The intraclass correlation coefficients assessing repeatability in reporting sensation types were greater than 0.70 for aching and burning and low for stabbing (0.42).

Conclusions: This population of low back pain patients was consistent in completing pain drawings, even over a period of time averaging eight months.

EVALUATION OF A TOOL TO ASSESS THE IMPACT OF WORKPLACE ORGANIZATION AND SAFETY CULTURE ON DISABILITY RATES

Ostry A., Stringer B., Berkowicz J., Schultz I., Ramsum D.

A number of studies carried out in the past decade have shown that workplaces organization and behaviour have an important impact on injury rates. Studies by Habeck in the United States show that a work culture which "empowers" workers produces lower injury rates than work cultures which are authoritarian. As well, in Canada, Shannon has shown that work organizations in which senior management takes an activist role in both health and safety and return to work programs have lower injury rates than organizations which do not promote these kinds of programs.

Questionnaires were obtained and reviewed, as were all relevant studies of workplace organization conducted over the past decade. The constructs most predictive in relation to chronic low back'disability were identified. Thus, the instrument developed for use in this investigation represents the best possible synthesis of the scientific literature over the past decade as well as current expertise in this field.

The instrument was tested on 90 companies in British Columbia, Canada. Because types and rates of injury differ across workplaces it was important to study sectors with high, moderate, and low disability rates. Sawmills were selected as an example of a sector with high injury rates and hosptial/nursing homes were selected as an example of a sector with low injury rates. Several sectors, includes wineries, breweries, and meat packing plants, were selected to represent organizations with "moderate" injury rates. Using WCB data for 1997, claims rates were calculated for companies in the three sectors. Within each of the three sectors, 15 companies with highest claims rates and 15 companies with the lowest claims rates were selected. The ability of the instrument to distinguish between the best and worst companies within each sector were then tested using ANOVA techniques of statistical analysis. Preliminary results indicate that the instrument is both reliable and valid. Development of a tool to identify the most salient workplace organizational and cultural factors in relation to disability rates is the first step in targeting and developing appropriate workplace strategies to reduce these rates.

CLASSIFICATION OF LOW BACK PAIN IN A WORKING POPULATION USING THE DALLAS PAIN QUESTIONNAIRE

Oxguler'', M. Morel Fatio', S. Le Gall, A. Leclerc, A. Gueguen, M. Piciotti, F. Boureau', 'Centre d'Evaluation et de Traitement de la Douleur, Hopital Saint-Antoine,Unite INSERM 88, centre de Reeducation, Readadaptation de Coubert, "'Societe de Medecine du Travail de l'Ouest de l'Ile de France.

Objective: There is a need for instrument permitting classification of low back subjects in a working environment and identifying the dysfunctional in contrast to coper.

Material and Method: 352 subjects working in various jobs in 1998, in the area of Paris, completed a self administrated questionnaire including the Dallas Pain Questionnaire (DPQ), Coping Strategy Questionnaire, Nottingham Health Questionnaire and Fear Avoidance Beliefs Questionnaire. This population included 210 subjects with sick leave of 7 days or more in the past 12 months and a control group of 142 workers, including 30 with low back pain. Factorial analysis and clustering of the DPQ was performed for the 240 low back sufferers (VARCLUS procedure in SAS software).

Results: Two factors were extracted by factorial analysis of the DPQ items: work and activity disability dimension (items 1 to 11); psychological distress (items 12 to 16). Classification of subjects according to these two factors will be described as well as the relationship with answers to other questionnaires.

Conclusion: DPQ was designed to measure consequences of LBP. Our results indicate that it can been used also in a working environment.

ANALYSIS OF THE EFFICIENCY OF THE EPIDURAL ANALGESIA IN LOW BACK PAIN SYNDROME

Oana D. Predescu. Roger Florescu, Univ of Medicine and Pharmacology "Carol Davila" Bucharest, Orthopaedics and Traumatology Hospital "Foisor", Dept. of Anesthetics, Bd. Ferdinand 35, 79826 -Bucharest, Roumania

Aim of Investigation: to prove the effectiveness (pain* relief, improve the movements amplitude**, hospitalization time, drugs cost, acute vs. chronic pain syndrome) of the epidural analgesia as a single treatment method in low back pain syndrome.

Methods: 200 patients with age between 20 and 75 years were admitted in our clinic between 1995 and 1998 with the diagnosis:lumbar spondylitis, unoperated lumbar disc hernia or operated disc hernia but with painfully postoperative sequels, congenital anomalies like rachiskysis or uni/bilateral sacralisation. We used the epidural analgesia as single treatment method: decubitus position, involved side down; loss-of-resistance technique, negative aspiration; inject local anesthetic and steroid; patient in decubitus position for 10-15 min; follow-up: if worse, use other therapy, if symptoms are improved but persistent, repeat block. The epidural injected substances were: lidocaine I - 1.5% 10 - 15 ml plus hydro-cortisone acetate 100 mg.

Results: 124 (62%) patients had good results after one single injection, in 73 (36.5%) cases were necessary a second injection (and the patients come back to their normal life) and only in 3 (1.5%) cases the epidural anesthesia had not relieve the pain and the patient needed surgical intervention.

Conclusions: The epidural anesthesia is a good method in pain relief and improve the leg functionality in acute and even chronic low back pain syndrome; the method reduce the immobilization and the hospitalization time, permitting that the operation should be delayed or even postponed. *analog-visual scale; **common tests

DEVELOPMENT OF A PAIN BEHAVIOUR CODING SYSTEM FOR USE IN REAL TIME DURING A PHYSICAL EXAMINATION OF LOW BACK PATIENTS

Kenneth Prkachin & Elizabeth Hughes*, Unive of Northern BC, Prince George BC, Canada V2N 4Z9, Izabela Schultz & Peter Joy, Workers' Compensation Board ofBC, Richmond, BC, Canada

Aim of Investigation: To develop a method for observing pain behaviour in a clinical examination for low back pain, to evaluate a training protocol and to evaluate the reliability of the method.

Method: A pain behaviour coding system was developed, integrating available methods with research on pain expression. Five behaviour classes were defined - guarding, touching, words, sounds, and facial expressions. The system was integrated with a standardized physical examination to be applied during 36 natural epochs. A training protocol was evaluated in a multiple baseline experiment.

Results: Following brief training, observers were quite accurate in the detection of the pain behaviours. Both groups of participants showed significant improvements in accuracy after a more extensive training program. Trained observers' ratings showed test-retest reliability (Pearson r) of .75 over two weeks. Applicability of the protocol in situ and its reliability are currently being evaluated.

Conclusions: It is possible to parse a standardized physical examination into meaningful epochs for evaluating pain behaviour. Training that involves precise criteria, video examples and opportunities to practice improves observers' accuracy and reliability. The findings suggest that it is feasible to apply the protocol in prospective studies of pain behaviour and disability.

Acknowledgments: Supported by the Workers' Compensation Boards of Alberta and British Columbia.

SPINAL CORD STIMULATION FOR PREDOMINANT COMPLAINTS OF CHRONIC, INTRACTABLE LOW BACK PAIN

Ralph F. Rashbaum. Donna D. Ohnmeiss, Texas Back Inst Research Foundation and the Texas Health Research Inst; Piano, Texas, USA

Aim of Investigation: To evaluate spinal cord stimulation (SCS) in the treatment of patients with predominant complaints of chronic, intractable, low back pain.

Methods: The study group consisted of the consecutive series of our first 41 patients (21 males, 20 females; mean age 47.9 years, range 28 - 83 yrs) who underwent SCS for predominant complaints of low back pain. The mean symptom duration was 82.9 months. All but three patients had previously undergone lumbar spine surgery (mean 2.3 prior surgeries). All trial stimulation procedures were performed under local anesthetic with the patient providing feedback concerning pain relief achieved with various lead placements and settings. If one lead did not provided acceptable relief in all the areas needed, placement of a second lead was pursued. One lead was used in 4 patients and two leads were used in 37 patients. The receiver was implanted in the 36 patients who experienced adequate relief (>50% pain relief) during a multi-day trial period.

Results: Responses to a follow-up questionnaire (a negative response was assigned if no follow-up was obtained for a patient) indicated that 72% of patients would recommend SCS to someone with similar problems, 58% were satisfied, and 69% would have the procedure performed again if they had known their outcome prior to implantation. Re-operations included 4 units removed due to loss of adequate pain relief, lead repositioning in 6 patients, and in one patient the extension wires were revised and later replaced.

Conclusions: SCS can provide acceptable results in this very difficult to treat population with predominant complaints of chronic axial low back pain and who are carefully screened for this device.

Acknowledgment: Sponsored in part by a grant from Medtronic Neurological Division; Minneapolis, MN

OCCUPATIONAL AND PSYCHOSOCIAL ADJUSTMENT AFTER HERNIATED LUMBAR DISK SURGERY: FOLLOW-UP STUDY

Rebolledo P.. Valcarcel M., Gonzalez M., Marre B., Carbonell, C. Hospital del Trabajador, Santiago, Chile

Aim of Investigation: Psychosocial factors often influence prognosis and return to work in patients with low back pain. This study pretends to evaluate occupational and psychosocial long-term adjustment in injured workers with hemiated lumbar disk who underwent laminectomy.

Method: This is a study of Cases and Controls. Sample was selected of patients operated between 1991 and 1995 in our institution. Cases were constituted by 47 male patients who underwent first spinal surgery with psychosocial stressors and/or emotional disorder, detected before surgery. Controls were 44 men without these factors. In both of them, we analyzed demographic data, clinical data after surgery and during 1998, patients were interviewed with a semi structured psychosocial questionnaire to evaluate occupational adjustment and quality of life.

Results: Demographic data were similar between cases and controls. Age average was 38.9 (19-57); educational level was 9.1 (1-17) years average; 92% were married and 72% were blue-collar workers. Time elapsed until return to work in the Cases was 72 days (30-450) and in the Controls group was 62 days (30-230) p=n.s. Occupational activity: Time of follow-up was 4,3 years average (3-7). 96% of Cases were working and 13 of them (29%) were relocated to lighter work after surgery. 100% of Controls were working and 9 of them (20%) were relocated (p=n.s.). 15 patients (33%) of Cases group have lower performance in their jobs. Only 3 patients (7%) of Controls group have the same condition (p<0.05). Job satisfaction was similar between cases and controls. Psychosocial impact: 83% of Cases and 82% of Controls perceive a good quality of life. 60% of Cases and 52% of Controls quit sports activity. Low back pain is present in 36% of Cases and 14% of controls (p<0.05).

Conclusions: a) Early detection and managment of psychosocial factors associated hemiated lumbar disk, shows similar outcome respect those without this risk factors, b) There are a good quality of life and occupational satisfaction in both groups, c) Cases feel a lower performance in their jobs and they refer more pain, probably maladaptative illness behavior.

MANAGEMENT OF PAIN IN MOBILE SPINE SEGMENTS

Schaffer S.*. (SPON Schaffer-Vargas G.), Mejia A.*, Femandez C.*, Unidad Integral Del Dolor Centre Clinico Profesional Caracas, Caracas, Venezuela

Aim of Investigation: To investigate the incidence of Pain in Mobile Spine Segments (PMSS) in our Unit. To determine the different pathologies that cause PMSS. To establish the effectiveness of the management and treatment of PMSS in our Unit.

Materials and Methods: Retrospective and prospective study of 180 patients with PMSS. The Pain evaluation methods were: verbal rating scale (VRS), Spanish version ofMcGill Pain questionnaire, Pain Relief Scale (PRS), proposed at second consultation. Patients were evaluated and treated by a multidisciplinary team.

Results: 156 patients suffered of PMSS, of which 95 suffered of backpain and 61 ofcervicobrachial pain. All patients suffered PMSS for over than 337.5 days in average before treatment. The different pathologies related with PMSS were: Degenerative affection 26,92%; Back Pain 26,92%; Fibromyalgic Syndrome 23,71%; Radiculopathy 8,97%; Traumatic 7,05%; Post-surgical 6,41%. 16,02% patients had an associated lumbar and cervical pain. Time in which patients recognised by themselves, a decrement pain greater or equal to 60% according to PRS was 14,28 days post-treatment. The protocol of treatment that we follow in our unit is:

The association ofdiclofenac, carisoprodol, tricyclics antidepres-sants, analgesics paravertebral blocs with bupivacaine, trigger points infiltrations with bupivacaine, and rehabilitation program.

Conclusions: The multidisciplinary management of PMSS associating different drugs and several techniques are possible, with excellent results in a relative short time.

A NEW PUNCTURE APPROACH TO THE EPIDURAL LATERAL RECESS FOR LOW BACK PAIN

Song Wenge. Fu Zhijian, Dept of Pain Management, Shandong Provincial Hospital, 324 Jingwulu Weiqilu, 250021, Jinan, Shandong Province, P.R. China

Aim of Investigation: To develop a new approach to make drugs concentrating on the focus and improve effects of the treatment of low back pain.

Methods: Anatomy, X-ray and CT photographs were studied, then a new approach via the medial margo of facet Joint to epidural lateral recess was developed. A puncture procedure was designed. The analgesic was injected via the approach to 200 cases suffered from radiculoneuritis (group A); collagenase to 312 cases suffered from prolapsed lumbar intervertebral disc (PLID) (group B). The results were observed and compared with that of the traditional approach via intervertebral foramen under X-ray monitoring.

Results: The success rate of the puncture was 100%. 6 of 512 cases received X-ray monitoring during the procedure, which proved that the puncture point and the positions of needle tip in both facet joint and lateral recess were all correct. The satisfactory rate was 86.67% (group A) and 90.00% (group B), following up one year 75.00% and 93.10% respectively. There was no difference between group B and those patients with the traditional approach.

Conclusions: The injection of the analgesic or collagenase into the epidural lateral recess is an effective and safe technique for low back pain caused by radiculoneuritis or PLID. The distance of the approach is short, the damage to tissues is light and the bone mark is clear. It is easy to master this technique without X-ray monitoring.

Acknowledgments: Supported by a MONSANTO Company.

LEG LENGTH DISCREPANCIES, SCOLIOSIS AND LOW BACK AND PELVIC PAIN

Augusto Manganiello, Radiology - Via Savonarola 175 - 35137 Padova- Italy

Diagnostic imaging shows that, during growth, leg length discrepancies (LLD) can cause various scoliotic deviations. Curves that are initially moderate, non-structural and mobile may subsequently diminish, remain stationary or progress and become structural. The course ofscoliosis is above all affected by the load distribution at the lumbosacral level since, if it is asymmetric, it may produce: wedging of the intervertebral disc L4-L5 and/or L5-S1; wedging of L4 and/or L5; pelvic torsion with consequent asymmetric drop of the sacrum. By modifying the orientation of the resting surface of the sacrum and the basal vertebrae, these changes cause spine deviation in the frontal plane on the side of the greater load. There will be either a progression or a reduction of the curve according to whether the lateral deviatin due to asymmetric loading sets up an acting synergism or a compensation. If, however, the load distribution at the lumbosacral level is symmetric, the curve will usually be stationary. Furthermore, the overload at the lumbosacral level may produce: muscular and ligamentous stress; premature degenerative diseases of the disc-somatic and the interapophyseal joints L4-L5 and/or L5-S1; subluxation of the sacroiliac joint with anterior rotation of the corresponding ilium. These alterations may give rise to low back and pelvic pain of mechanical origin. The pain, with or without sciatica, more often affects the side of the lesser load if caused by hcmiary pathology; otherwise, it almost always affects the side of the greater load. In conclusion, it emerges from our findings that LLD constitute the initial 'noxa' which provokes biomechanical responses. These may produce various curves, trunk imbalance and asymmetric loading distributions. The overload at the lumbosacral level plays a prominent role in the pathogenesis ofscoliosis and low back and pelvic pain.

THE EFFECTS OF FAILURE FEEDBACK AND PAIN-RELATED FEAR IN CHRONIC LOW BACK PAIN (CLBP)PATIENTS.

Anja van den Hout. Johan Vlaeyen, Aukje Soeters, Ruud Houben & Madelon Peters. Inst for Rehabilitation Research, P.O. Box 192, 6430 AD Hoensbroek, NL.

Aim of the Investigation: To investigate the effects of failure feedback and pain-related fear on pain report, pain tolerance and pain avoidance, and moreover, the moderating role of negative affectivity (trait) and the mediating role of negative affect (state).

Methods: 76 CLBP-patients were divided into high and low pain related fear groups and within each group, randomly assigned to failure or success feedback (manipulation). In the first part of the study, subjects filled out a "social empathy test" and experimenter 1 (A.S.) subsequently gave false failure or success feedback. In part 2 of the study, experimenter 2 (R.H.), who was blind for the condition, administered two lifting tasks. During the first task pain reports were rated by means of a 100-point VAS-scale and tolerance time was clocked. During the second task, tolerance time was clocked once more, but now the subject could choose a bag out of 10 bags with different weights. Pain avoidance was operationalized as the product of weight and time. Trait negative affectivity was measured at baseline and negative state affect after the manipulation.

Results: Pain-related fear and gender both significantly predicted pain report and tolerance (p<0.05). As for failure manipulation, only marginal significance was found (p<0.1). With regard to pain avoidance, pain-related fear, gender and failure manipulation were predictive, but failure manipulation not in the hypothesized direction. Negative affect did not mediate the effects of failure feedback, nor did negative affectivity moderate the effects of failure feedback.

Conclusions:Pain-related fear decreased pain tolerance and increased pain report and avoidance in CLBP. These findings are in line with the state-of-the-art literature on pain-related fear. Failure manipulation, surprisingly, decreased pain avoidance and had marginal predictive value in pain report and pain tolerance. Negative affect nor negative affectivity did have any influence on pain report, tolerance or avoidance.

Acknowledgments: Supported by the Dutch Organization for Scientific Research (NWO) Grant n°. 940-31-004; The study was conducted in collaboration with Maastricht Univ.

MEASUREMENT OF PHYSICAL ACTIVITY BY TRIAXIAL ACCELEROMETRY IN CHRONIC LOW BACK PAIN

J.Verbunt. G. vd Heijden*, H. Seelen*, P. Heuts, J. Vlaeyen, C. Pons*, A. Knottnerus*. Rehabilitation Foundation Limburg, P.O. Box 192, 6430 AD Hoensbroek, NL. Aim of the Investigation: Evaluation of the validity ofatri-axial accelerometer for measuring physical activity in daily living in patients with chronic low back pain.

Methods: In patients with chronic low back pain physical activity was assessed by a tri-axial accelerometer measuring whole body acceleration during daily living over a period of 14 days. During the same period energy expenditure due to physical activity was calculated as the ratio of average daily metabolic rate (ADMR), measured by the doubly labelled water technique, and basal metabolic rate (BMR), assessed by ventilated hood measurement.

Results: 13 patients, 9 male and 4 female, with chronic nonspecific low back pain participated in this study. Mean age was 45,5 ± 4,6 years, mean duration of complaints was 11,7±7,3 years and mean Roland Disability Score was 13,I±7,1. The Spearman-Rank Correlation between the tri-axial accelero-meter and energy expenditure was 0.79 (p0.01).

Conclusions: The results show that the tri-axial accelerometer is a valid instrument for measuring daily activity in patients with chronic low back pain.

Aknowledgements: The study was conducted in collaboration with Maastricht Univ and the Inst for Rehabilitation Research and was supported by Foundation 'De Drie Lichten' in the Netherlands and Grant nr. 904-65-090 of the Dutch Organization for Scientific Research (NWO-MW).

GRADED EXPOSURE IN "KINESIOPHOBIC" CHRONIC LOW BACK PAIN (CLBP) PATIENTS: A SINGLE CASE EXPERIMENTAL DESIGN.

Johan W.S. Vlaeyen ''^Jeroen de -long*', Mario Geilen*2, Peter H.T.G. Heuts 2 'Inst. for Rehab. Research, Hoensbroek, rehabilitation Centre "Hoensbroeck", The Netherlands.

Aim of Investigation: To examine the effectiveness of a cognitive-behavioral graded exposure (GEXP) treatment as compared to graded activity (GACT) in reducing pain-related fears and pain disability in CLBP patients reporting substantial fear ofmove-ment/(re)injury.

Methods: Four consecutive CLBP patients who were referred for outpatient behavioral rehabilitation, and who reported substantial fear ofmovement/(re)injury (Tampa Scale for Kinesiophobia score > 40), were included in the study. After a baseline measurement period, the patients were randomly assigned to one of two treatments. In treatment A, patients received GEXP first, followed by GACT. In treatment B, de sequence of treatment modules was reversed. Sixty-three daily measures of pain-related cognitions and fears were recorded with visual analog scales. Before and after the treatment, the following measures were taken: pain-related fear, pain catastrophizing, and pain disability.

Results: Using time series analysis (AREG) on the daily measures, we found that for the majority of the dependent variables trend changes were observed when GBXP followed either baseline or GACT, and not at the other transitions (baseline - GACT, GEXP -GACT), suggesting that pain-related fear was only reduced by the CBE. Decreases in pain-related fear also concurred with decreases in catastrophizing and pain disability.

Conclusions: Cognitive-behavioral graded exposure appears to be a promising treatment choice for the subgroup of CLBP patient who report substantial fear ofmovement/(re)injury.

Aknowledgements: Supported in part by Grant nr. 904-65-090 of the Dutch Organization for Scientific Research (NWO-MW).

THE POSITION OF NEUROSTIMULATION IN THE TREATMENT OF FAILED BACK SURGERY SYNDROME

Ivan VRBA. Jiri Kozak, ICU Hospital na Homoice, Roentgenova 2, 151 19 Praha 5, Czech Republic

Aim oflnvestigaton: Failed Back Surgery Syndrome (FBSS) is a complex syndrome that results in substantial social and economic burdens. It is multifactonal in etiology and successful treatment is very and problematic. One of the possibilities to treat FBSS is a neuromodul ation.

Methods: Several methods exist for the treatment of FBSS. We have used multidisciplinary approach. We wanted to form a suitable therapeutical ladder for the treatment. We have tried to estimate the treatment effectiveness, cost effectiveness and side of various methods used in the treatment of FBSS.

Results: In accordance with published results neuromodulation has been gaining importance. But it is necessary to use these methods correctly. To be successful, patients must be selected carefully for the therapy and the appropriate neuromodulation therapy should be selected for each patient. When used long lasting therapy is used, it is cost-effective compared to other methods of FBSS treatment. And the therapy provides long-lasting pain relief in 60 - 65% of patients with minimal side effects.

Conclusions: Neuromodulation procedures provide a non-destructive and reversible approach to the treatment ofFBSS. Our target is to introduce more of these methods, especially SCS, in the treatment ofFBSS in our country, because neuromodulation therapy provides significant improvement for many patients. The growth of the use of neuromodulation be promoted actively by physicians, patients, and payers and we all must improve coordination in the future.

NAPHTHALAN OIL WITH ULTRASOUND IN COMPLEX TREATMENT OF PAINFUL SYNDROME IN THE PATIENTS WITH SPINAL OSTEOCHONDROSIS

R.G. Zeynalov*. A.V. Musayev*, Res. Inst. ofMed. Rehab, and Natural Therapy Factors, 3, Khatai St., 370008, Baku, Azerbaijan

Aim of Investigation: To develop complex methods of painful syndrome in the patients with spinal osteochondrosis using naphthalan oil with ultrasound.

Methods: The patients underwent complex treatment using naphthalan oil, a unique therapy factor of Azerbaijan and ultrasound. Clinico-neurologic status of the patients as well as the state of peripheral circulation (rheovasography) and neuromuscular apparatus (global electromyography) were studied.

Results: Positive effect showed 661 patients with painful syndrome of spinal osteochondrosis. Significant reduction of painful syndrome was observed in localization ofpathologic process in lumbar level (77-80%) than cervical level (68-70%). The correlation of clinical and electrophysiologic values had been observed. It was stated that naphthalan oil with ultrasound was more 10-12% effective than only ultrasound.

Conclusion: Naphthalan oil with ultrasound is an effective method of treatment and can successfully be used in complex treatment of painful syndrome in the patients with spinal osteochondrosis.

CENTRAL CANAL STENOSIS

Dipak Roy, Pain Clinic, Calcutta 700 042, WB, India

Aim of Investigation: In Pain Clinic, Male patients between 30-55 yrs. presented with backache, buttockache, early morning stiffness, dorsolumber pain, restricted back movement all directions, claudi-cation pain lower limb and back with paresthesia and sensory loss, limited chest expansion, deformity of spine with or without P/H of Tuberculosis/Trauma, with or without P/H of spinal deformity in family were investigated for diagnosis, prognosis and treatment.

Methods: Clinically determined: Laboratory Tests including He-matological, Biochemical, Immunological; various Radiological and Radioisotope studies and Electrophysiological tests etc. for Anatomical and Pathological diagnosis, Conservative Pharmacol-ogical, Physical, Psychotherapy of appropriate needs; Rehabilitation program including assisted devices; change of life-style etc. were implemented and continued over time with regular follow ups. Consultations with appropriate specialties were done.

Results: Sequale/Complication of Caries Spine, Ankylosing Spon-dylitis and 0 A Spine treated by Conservative Programs as none could afford Operative Treatment. Conservative Treatment (not Palliative) Programs for Chronic Partially Disabling Pain, Loco-motor and Sensory disturbance in working age group were rewarding with development of insight and strong personality with supportive psychotherapy and psycho-education. Follow-up regularly for treatment and rehabilitation appeared egosyntonic.

SACROILIAC JOINT BLOCK TO TREAT LOW BACK PAIN DURING PREGNANCY

Yukihiro Ofusa*. Takeshi Kitoh*, Hiroaki Ina* (SPON: K. Oh-seto), Dept ofAnesthesiology and Resuscitology, Shinshyu Univ School of Medicine, Matsumoto, Nagano, 390-8621, Japan

Aim of Investigation: The incidence of low back pain due to pregnancy is reported to be about 50%. We investigated the safety and efficacy of sacroiliac joint block to treat low back pain during pregnancy.

Methods: We treated 8 pregnant women (27.3 years, 23.0 weeks of pregnancy, mean) with intolerable low back pain and tenderness in the region of the posterior superior iliac spine. After informed consent was obtained, we inserted a needle using a posterior approach at 2-3cm inferior to the bilateral posterior superior iliac spines without fluoroscopic guidance. We injected a total of 10ml of 1% mepivacaine with 4mg dexamethasone into the bilateral sacroiliac joints. If necessary, 10ml of 1% mepivacaine without steroid was injected at a two-week interval. Pain relief was assessed by using visual analog pain scores (VAS) before and 24hrs after each block.

Results: The number of blocks performed was 1 in 4 patients, 2 in 2 patients, 6 in 1 patient and 8 in 1 patient. The VAS was significantly decreased after the first block in all patients (Wilcoxon's matched-pair rank-sum test, P<0.01). There were no technical difficulties or complications. All patients had normal a pregnancy course and delivery.

Conclusions: The sacroiliac joint block was found to be safe and effective to treat low back pain during pregnancy.

METHYLCOBALAMIN AS AN ADJUVANT MEDICATION IN CONSERVATIVE TREATMENT OF LUMBAR SPINAL STENOSIS

Warapom Waikakul. Dept ofAnesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol Univ, Bangkok, Thailand. Sarana-tra Waikakul, Dept ofOrthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol Univ, Bangkok, Thailand.

Aim of Investigation: To find out the clinical effects ofmethylco-balamin on the conservative treatment of degenerative spinal stenosis.

Methods: The study was operated as an control single blind trial with 2 year follow up. Inclusion criteria were degenerative spinal stenosis without strong indication for surgery. The patients were randomly allocated into two groups. In the first group, the trial group, the patients received conventional management of spinal stenosis including education, physical therapy, NSAIDS, orthopae-dic appliance, Vitamin 31-6-12 and 1.5 mg ofmethylcobalamin per day. The control group was treated with similar management except no methylcobalamin was given. Improvement of neurological signs, symptoms, and pain were compared between the groups.

Results: Most of the patients in both groups had no significant difference in terms of pain and neurological improvement, except the neurogenic claudication distance was significantly improved in the trial group.

Conclusion: Methylcobalamin could improve neurogenic claudication distance in degeneration spinal stenosis.

TRADITIONAL CHINESE MEDICAL THERAPY IN LOWER BACK PAIN WITH LEG PAIN: AN OBSERVATION OF 103 PATIENTS.

Yingsheng Han*, Ping Su. Wei Han*, The Inst of Mechanical Engineering Hospital and Clinic, #97 Heping West Road, Shijiaz-huang City, Hebei Province, P. R. China, 050003

Aim of Investigation: To evaluate the use of traditional Chinese massotherapy as a conservative approach to treat the lower back pain with leg pain patients.

Methods: Individual patient pain relief scores were calculated after massotherapy at the tenderness points along the channel and collaterals in Chinese Medicine once per day for 15 days and some followed by injection oflidocaine and dexamethasone at the massage points.

Results: A total of 103 patients (male 69; female 34) between the ages of 20 and 50 were diagnosed with lower back pain without disc hemiations. Sixty-one of 103 (59%) had lower back pain and 42/103 (41 %) were accompanied by leg pain. The duration of complaints was between 1 week to 2.5 years. There were 154 tenderness points in 103 patients, including 81 in lumbar and fundus region, 45 in glutaeus, and 28 in leg. After one to two courses of treatment, 67 cases (65%) completely released pain; 11 cases (10.7%) effectively reduced pain and 4 patients (3.9%) were ineffective. 41 cases were interviewed after one year and all were cured.

Conclusion: Massotherapy at the tenderness points along the channel and collaterals acts as an effective approach to treat lower back pain with leg pain.

Acknowledgment: Supported in part by The Institute of Mechanical Engineering Grant.

CONTROLLED-RELEASE OXYCODONE IN CHRONIC BACK PAIN: A COST ANALYSIS IN AN HMO POPULATION.

L.P., Cambridge, MA and Norwalk, CT 06850-3590 USA.

Aim of Investigation: Chronic back pain is a common medical condition second only to upper respiratory infections in the number of visits to physicians offices in the USA. Societal costs are estimated to be up to $50 billion annually. The aim of this study was to determine the economic impact of initiating therapy in chronic back pain with an opioid, controlled-releasc (CR) oxycodone. The focus of the analysis was on direct medical costs from the perspective of the managed care organization.

Methods: A retrospective analysis of a managed care (HMO) claims database was undertaken to identify patients with a diagnosis ofspondylosis who had received a prescription for oxycodone CR (OxyContin*). Direct medical costs for spondylosis were examined for 90 days before and 90 days following initiation of oxycodone CR. All medical costs and utilization were reflected in four categories: facility inpatient, facility outpatient, professional services and other.

Results: 192 patients who received and filled a prescription for oxycodone CR were identified from an HMO database of 51,727 patients with claims for non-malignant chronic pain. 141 patients had at least one claim for spondylosis or osteoarthritis. Of those, 68 patients then fulfilled criteria for the availability of claims data for spondylosis only, for 90 days prior and 90 days following the initiation of oxycodone CR. In these 68 patients, direct medical costs related to spondylosis were $143.68 per patient less during the 90 days following initiation of oxycodone CR than during the 90 days prior to it. The greatest cost savings occurred in the category of professional services ($284.67).

Conclusions: These results provide preliminary evidence that the use of oxycodone CR for chronic back pain may reduce direct medical costs related to spondylosis.

Acknowledgments: Supported by funding from Purdue Pharma L.P.; Lloyd P. Haskell, MD is an employee of Purdue Pharma L.P.

ROLE OF SURGERY IN COCCODYNIA (REPORT OF FOUR CASES)

H. Nayeb Aghayee. A. Saadat Niaki, (Spon: B. Maiek), Imam Hos-sein Hospital, Neuro Surgical and Anesthesia Dept. Medical Univ ofShahid, Beheshti Madani St. Tehran 16179 Iran

Aim of Investigation: To show the role ofCoccygectomy in pain relief of cases ofCoccodynia.

Method: Since 1995-98, four cases ofCoccygeal pain (Cocco-dynia) were referred to neurosurgical unit for surgery. All cases didn't respond to conservative therapy including the rest, sitting on soft ring seats, anti-inflammatory and estroidal drugs, physiotherapy, combination injection of local Anesthetic and methyl prednis-olone at coccyx. The patients were two male and two female. Ages were between 30-50 years. Mean duration of pain was 2 years (1- 3 years). Sacro-coccygeal joint fracture was shown in two cases in X-ray. In these cases, under general anesthesia and prone position by a midline incision, complete resection of coccyx was performed. Result: Complete pain relief without any complication has been achieved in three patients and in other case, with neurotic personality, 80% response has been accomplished.

Conclusion: The Coccygectomy is a curative treatment for refractory coccodynia. Therefore, we recommend the coccydynia due to sacrococcygeal-fracture are the best candidate for surgery.

RECALL BIAS FOR PAIN STIMULI CORRELATES WITH COST OF BACK PAIN TREATMENT

Tamar Pincus. Steve Vogel, Stan Newman. Dept. of Psychology, Royal Holloway, Univ of London, Egham, Surrey TW20 OEX, UK.

Aim of Investigation: To investigate how selective recall of pain information correlates with cost of health services utilisation for back pain in low back pain patients, above and beyond physical factors and self-report of affect.

Method: A retrospective study of 63 back pain patients in primary care. The proportion of pain words out of total words recalled was entered in a hierarchical regression after demographics, pain and disability, depression and anxiety. The outcome measure was cost of health utilisation for back pain over the last 12 months, calculated for each patient individually from case notes.

Results: Selective recall accounted for 8% of the variance of Total cost (P<0.05). The only other significant coefficient was for duration of pain. A breakdown revealed that Pain intensity was correlated with GP visits. Depression was correlated with appointments with the in situ osteopath, and recall bias was correlated with referral to experts. Since referrals account for a large proportion of total cost, recall bias emerges of the main predictor of total cost.

Conclusion: Recall bias should be investigated in prospective cohorts, to establish the link with cost and utilisation of services. Cognitive bias may represent vulnerability for the development of enhanced distress/disability, and should be identified through screening in individuals who would benefit from early psychological intervention.

Acknowledgment: Supported by MRC fellowship.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.428 - 433

   

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