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  1. Article: Psychotropic medication in chronic spinal disorders.

    Polatin, Peter B / Dersh, Jeffrey

    The spine journal : official journal of the North American Spine Society

    2004  Volume 4, Issue 4, Page(s) 436–450

    Abstract: Background context: Optimal treatment of nonmalignant chronic spinal disorders (CSDs) may require the use of one or more nonopioid psychotropic medications. Vast research literature has documented high rates of psychiatric disorders in patients with ... ...

    Abstract Background context: Optimal treatment of nonmalignant chronic spinal disorders (CSDs) may require the use of one or more nonopioid psychotropic medications. Vast research literature has documented high rates of psychiatric disorders in patients with CSDs. Psychotropic medications are one type of effective treatment for these disorders. Many medications of this type are also used as adjuvants to primary analgesic medications.
    Purpose: Physicians treating CSDs may have little training and experience in prescribing psychotropic medications. Further, they may possess limited information about the efficacy of these types of medications in treating psychiatric disorders comorbid with CSDs or as adjunctive analgesics. Because of the wide variety (antidepressants, anxiolytics, sleep-promoting agents, anticonvulsants, neuroleptics, muscle relaxants) and numerous indications for psychiatric medications, a concise review of the use of psychotropic medications with CSD patients is offered for the spine specialist.
    Study design: A systematic review of the contemporary English literature on psychotropic medications in the CSD population.
    Methods: A computerized search of MEDLINE was performed on all English literature published from 1982 to August 2002.
    Results: Psychotropic medications have been found to be very efficacious in the large subgroup of patients with CSDs with psychiatric comorbidity, particularly patients with the common constellation of depression, anxiety, excessive somatic complaints, insomnia and irritability. Although the type of medication indicated depends on the particular psychiatric syndrome(s), antidepressants have been found to be extremely useful with the constellation described above. There is less evidence to support the use of nonopioid psychotropic medications in the treatment of nociceptive pain, although clinical experience indicates that some individuals demonstrate a marked analgesic response. Research support for the efficacy of particular psychotropic medications in treating neuropathic pain is stronger, although more controlled research is clearly needed.
    Conclusions: Psychotropic medications are extremely useful in the treatment of psychiatric disorders comorbid with CSDs and modestly useful as analgesic adjuvants, particularly with pain of neuropathic etiology. Familiarity with these medications will aid the primary treating physician in optimizing outcomes in this difficult group of patients.
    MeSH term(s) Chronic Disease ; Comorbidity ; Female ; Follow-Up Studies ; Humans ; Incidence ; Male ; Mental Disorders/drug therapy ; Mental Disorders/epidemiology ; Mental Disorders/psychology ; Pain Measurement ; Psychotropic Drugs/therapeutic use ; Risk Assessment ; Severity of Illness Index ; Spinal Diseases/drug therapy ; Spinal Diseases/epidemiology ; Spinal Diseases/psychology ; Treatment Outcome
    Chemical Substances Psychotropic Drugs
    Language English
    Publishing date 2004-07
    Publishing country United States
    Document type Comparative Study ; Journal Article ; Review
    ZDB-ID 2037072-6
    ISSN 1529-9430
    ISSN 1529-9430
    DOI 10.1016/j.spinee.2004.01.012
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  2. Article: Chronic pain and psychopathology: research findings and theoretical considerations.

    Dersh, Jeffrey / Polatin, Peter B / Gatchel, Robert J

    Psychosomatic medicine

    2002  Volume 64, Issue 5, Page(s) 773–786

    Abstract: Objective: Numerous studies have documented a strong association between chronic pain and psychopathology. Previous research has shown that chronic pain is most often associated with depressive disorders, anxiety disorders, somatoform disorders, ... ...

    Abstract Objective: Numerous studies have documented a strong association between chronic pain and psychopathology. Previous research has shown that chronic pain is most often associated with depressive disorders, anxiety disorders, somatoform disorders, substance use disorders, and personality disorders. The primary objective of this review article is to describe the nature of the relationship between chronic pain and each of these types of psychopathology. In addition, this article will explore how each of these disorders are expressed within the context of chronic pain, with a consideration of both diagnostic and treatment issues.
    Methods: Medline and PsychLit searches of the chronic pain/psychopathology literature from 1980 through 2000 were conducted using the keywords chronic pain, psychopathology, psychiatric disorders, and psychological disorders.
    Results: The relationship between chronic pain and psychopathology has generated substantial empirical and theoretical interest, with depressive disorders receiving much of the attention.
    Conclusions: Although no single theoretical model can fully explain the causal relationship between chronic pain and psychopathology, a diathesis-stress model is emerging as the dominant overarching theoretical perspective. In this model, diatheses are conceptualized as preexisting, semidormant characteristics of the individual before the onset of chronic pain that are then activated and exacerbated by the stress of this chronic condition, eventually resulting in diagnosable psychopathology.
    MeSH term(s) Anxiety/diagnosis ; Anxiety/etiology ; Chronic Disease ; Depressive Disorder, Major/diagnosis ; Depressive Disorder, Major/etiology ; Humans ; MMPI ; Pain/diagnosis ; Pain/drug therapy ; Pain/psychology ; Personality Disorders/diagnosis ; Personality Disorders/etiology ; Personality Inventory ; Psychiatric Status Rating Scales ; Somatoform Disorders/diagnosis ; Somatoform Disorders/etiology ; Substance-Related Disorders/diagnosis ; Substance-Related Disorders/etiology
    Language English
    Publishing date 2002-10-01
    Publishing country United States
    Document type Journal Article ; Research Support, U.S. Gov't, P.H.S. ; Review
    ZDB-ID 3469-1
    ISSN 1534-7796 ; 0033-3174
    ISSN (online) 1534-7796
    ISSN 0033-3174
    DOI 10.1097/01.psy.0000024232.11538.54
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  3. Article: The management of secondary gain and loss in medicolegal settings: strengths and weaknesses.

    Dersh, Jeffrey / Polatin, Peter B / Leeman, Gordon / Gatchel, Robert J

    Journal of occupational rehabilitation

    2004  Volume 14, Issue 4, Page(s) 267–279

    Abstract: Individuals with chronic illness and disability are among the most difficult patients to treat. The health-care provider is faced with an array of physical, psychological, and social factors, requiring adoption of a biopsychosocial approach to treatment. ...

    Abstract Individuals with chronic illness and disability are among the most difficult patients to treat. The health-care provider is faced with an array of physical, psychological, and social factors, requiring adoption of a biopsychosocial approach to treatment. This approach necessitates consideration of the benefits for the patient of remaining ill and disabled. These benefits have been termed the "secondary gains" of illness, and they may serve to perpetuate disability and illness behavior. This paper focuses on secondary gain and loss issues in patients with chronic, nonprogressive illness associated with chronic disability, who are evaluated and treated in medicolegal settings. In working with this population of patients, the health-care provider is faced not only with the usual secondary gains of illness (e.g., escape from family responsibilities), but must also deal with the myriad of secondary gain issues unique to medicolegal settings (e.g., seeking financial compensation). Consequently, identifying and managing secondary gain issues can be quite challenging. A model for managing these issues is presented here,following a more general discussion of secondary gain and related concepts. This model has proven very useful when incorporated into an effective rehabilitation program, such as the functional restoration approach to treating chronic musculoskeletal disorders. However, shortcomings of this model for managing secondary gain have become apparent. These shortcomings, and methods for overcoming them, are discussed. The overall purpose of this paper is to improve the health-care provider's ability to identify and manage both simple and complex secondary gain issues.
    MeSH term(s) Chronic Disease ; Disabled Persons/rehabilitation ; Humans ; Muscle Weakness/rehabilitation ; Primary Health Care/methods ; Primary Health Care/standards ; Treatment Outcome
    Language English
    Publishing date 2004-12-27
    Publishing country Netherlands
    Document type Journal Article ; Research Support, U.S. Gov't, Non-P.H.S. ; Research Support, U.S. Gov't, P.H.S.
    ZDB-ID 1171536-4
    ISSN 1053-0487
    ISSN 1053-0487
    DOI 10.1023/b:joor.0000047429.73907.fa
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  4. Article ; Online: Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders?

    Dersh, Jeffrey / Mayer, Tom / Theodore, Brian R / Polatin, Peter / Gatchel, Robert J

    Spine

    2007  Volume 32, Issue 9, Page(s) 1045–1051

    Abstract: Study design: An epidemiologic prevalence study.: Objectives: To clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSDs).: Summary of ... ...

    Abstract Study design: An epidemiologic prevalence study.
    Objectives: To clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSDs).
    Summary of background data: Few empirical data are available regarding the "chicken-or-egg" question of which occurs first: the injury or incident culminating in the painful CDOSD or the psychiatric disturbance.
    Methods: Subjects attended a tertiary interdisciplinary rehabilitation program. Psychiatric disorders were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID-DSM-IV). Psychiatric disorders were characterized as preexisting if they manifested themselves before the work-related injury claim (whether or not they resolved, continued, or reoccurred after injury). They were determined postinjury diagnoses only if they manifested for the first time after the injury claim.
    Results: A total of 38.7% of the present cohort had at least one preexisting major psychiatric disorder, while 98.9% developed one or more psychiatric disorders for the first time after injury onset (57.9% when pain disorder was excluded). The percentage of patients with preexisting psychiatric disorders was lower than general population base rates (48%). The first onset of certain psychiatric disorders was found to be elevated in patients only after the work-related injury; these included Pain Disorder (95.7%), Major Depressive Disorder (49.7%), and Opioid Dependence (15%). Moreover, 5 times as many patients with MDD, and 10 times as many with opioid dependence, developed these disorders for the first time after the injury.
    Conclusions: In general, psychiatric disturbance is not a risk factor for developing a CDOSD. Psychiatric disorders are much more likely to develop after the onset of the work injury, indicating that such injuries and accompanying stressors are likely to be precipitants, rather than consequences, of psychopathology.
    MeSH term(s) Adult ; Chronic Disease ; Cohort Studies ; Depression/epidemiology ; Female ; Humans ; Male ; Mental Disorders/epidemiology ; Middle Aged ; Occupational Diseases/epidemiology ; Occupational Diseases/psychology ; Prevalence ; Risk Factors ; Somatoform Disorders/epidemiology ; Somatoform Disorders/etiology ; Spinal Diseases/epidemiology ; Spinal Diseases/psychology ; Time Factors
    Language English
    Publishing date 2007-04-20
    Publishing country United States
    Document type Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/01.brs.0000261027.28779.52
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  5. Article ; Online: Psychiatric comorbidity in chronic disabling occupational spinal disorders has minimal impact on functional restoration socioeconomic outcomes.

    Dersh, Jeffrey / Mayer, Tom / Gatchel, Robert J / Towns, Ben / Theodore, Brian / Polatin, Peter

    Spine

    2007  Volume 32, Issue 17, Page(s) 1917–1925

    Abstract: Study design: A prospective study conducted at a tertiary functional restoration center for patients with chronic disabling occupational spinal disorders (CDOSDs), comparing treatment outcome status 1-year posttreatment of patients with specific ... ...

    Abstract Study design: A prospective study conducted at a tertiary functional restoration center for patients with chronic disabling occupational spinal disorders (CDOSDs), comparing treatment outcome status 1-year posttreatment of patients with specific diagnosed psychiatric disorders to those without.
    Objective: To evaluate if diagnosed psychopathology is a significant limiting factor in the successful interdisciplinary rehabilitation of CDOSD patients.
    Summary of background data: Research has demonstrated high prevalence rates of psychiatric disorders in patients with CDOSDs. Little is known about whether these disorders are associated with less successful treatment outcomes.
    Methods: A consecutive group of CDOSD patients (n = 1323) averaging 19 months of prerehabilitation disability were evaluated for psychiatric disorders with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Patients participated in a functional restoration program. A structured clinical interview addressing work status, recurrent injury, healthcare utilization, and financial claims closure was administered 1 year after discharge. Logistic regression analyses were conducted to determine the unique contribution of the specific DSM-IV disorders that were significantly associated with the outcomes.
    Results: Patients with panic disorder, antisocial personality disorder (PD) and dependent PD were >2 times more likely to be program noncompleters. For successful program completers, those with opioid dependence disorder (ODD) were 2.7 times less likely to return to work and 2.6 times less likely to retain work. Patients with ODD were also 2.1 times more likely to seek postrehabilitation treatment from a new provider.
    Conclusions: Despite intensive management of psychiatric disorders during interdisciplinary functional restoration for CDOSD, several disorders were found to be associated with less successful outcomes. Poorer work outcomes were more common with specific (and comorbid) Axis I psychiatric disorders. Opioid dependence was the single disorder associated most often with less successful outcomes. Despite these findings, the large majority of patients demonstrated successful outcomes. Depression did not independently link to less successful outcomes.
    MeSH term(s) Adult ; Antisocial Personality Disorder/epidemiology ; Chronic Disease ; Comorbidity ; Dependent Personality Disorder/epidemiology ; Disability Evaluation ; Employment ; Female ; Humans ; Logistic Models ; Male ; Mental Disorders/diagnosis ; Mental Disorders/epidemiology ; Mental Disorders/therapy ; Middle Aged ; Occupational Diseases/epidemiology ; Occupational Diseases/physiopathology ; Occupational Diseases/psychology ; Odds Ratio ; Opioid-Related Disorders/epidemiology ; Panic Disorder/epidemiology ; Patient Acceptance of Health Care ; Prospective Studies ; Psychiatric Status Rating Scales ; Recovery of Function ; Recurrence ; Socioeconomic Factors ; Spinal Diseases/epidemiology ; Spinal Diseases/physiopathology ; Spinal Diseases/psychology ; Spinal Diseases/rehabilitation ; Time Factors ; Treatment Outcome
    Language English
    Publishing date 2007-08-01
    Publishing country United States
    Document type Comparative Study ; Evaluation Studies ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/BRS.0b013e31811329ac
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  6. Article ; Online: Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders.

    Dersh, Jeffrey / Gatchel, Robert J / Mayer, Tom / Polatin, Peter / Temple, Owen R

    Spine

    2006  Volume 31, Issue 10, Page(s) 1156–1162

    Abstract: Study design: A prevalence study.: Objectives: To assess the prevalence of psychiatric disorders among a large group of patients with chronic disabling occupational spinal disorders (CDOSDs), using a reliable and valid diagnostic instrument.: ... ...

    Abstract Study design: A prevalence study.
    Objectives: To assess the prevalence of psychiatric disorders among a large group of patients with chronic disabling occupational spinal disorders (CDOSDs), using a reliable and valid diagnostic instrument.
    Summary of background data: Although unrecognized and untreated psychiatric disorders have been found to interfere with successful treatment of CDOSD patients, little data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in CDOSDs.
    Methods: Psychiatric disorders in a consecutive group of CDOSD patients (n = 1,323) attending a tertiary referral center for patients with CDOSD were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. RESULTS.: Overall prevalence of psychiatric disorders was found to be significantly elevated in CDOSD patients compared with base rates in the general population. A majority (65%) of patients were diagnosed with at least one current disorder (not including Pain Disorder, which is nearly universal in this population), compared with only 15% of the general population. Major Depressive Disorder (56%), Substance Use Disorders (14%), Anxiety Disorders (11%), and Axis II Personality Disorders (70%) were the most common diagnoses.
    Conclusions: Clinicians treating CDOSD patients must be aware of the high prevalence of psychiatric disorders in this population. They must also be prepared to use mental health professionals to assist them in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged disability in a substantial number of these chronic pain patients.
    MeSH term(s) Adolescent ; Adult ; Aged ; Chronic Disease ; Comorbidity ; Depressive Disorder/epidemiology ; Female ; Humans ; Male ; Mental Disorders/epidemiology ; Middle Aged ; Occupational Diseases/epidemiology ; Personality Disorders/epidemiology ; Prevalence ; Somatoform Disorders/epidemiology ; Spinal Diseases/epidemiology ; Spinal Diseases/physiopathology ; Spinal Diseases/psychology ; Texas/epidemiology
    Language English
    Publishing date 2006-05-01
    Publishing country United States
    Document type Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/01.brs.0000216441.83135.6f
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  7. Article: Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability.

    Dersh, Jeffrey / Gatchel, Robert J / Polatin, Peter / Mayer, Tom

    Journal of occupational and environmental medicine

    2002  Volume 44, Issue 5, Page(s) 459–468

    Abstract: The cost and prevalence of chronic work-related musculoskeletal pain disability in industrialized countries are extremely high. Although unrecognized psychiatric disorders have been found to interfere with the successful rehabilitation of these ... ...

    Abstract The cost and prevalence of chronic work-related musculoskeletal pain disability in industrialized countries are extremely high. Although unrecognized psychiatric disorders have been found to interfere with the successful rehabilitation of these disability patients, few data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in chronic disability. To investigate this issue, a consecutive group of patients with work-related chronic musculoskeletal pain disability (n = 1595), who started a prescribed course of tertiary rehabilitation, were evaluated. Psychiatric disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders. Results revealed that overall prevalences of psychiatric disorders were significantly elevated in these patients compared with base rates in the general population. A majority (64%) of patients were diagnosed with at least one current disorder, compared with only 15% of the general population. However, prevalences of psychiatric disorders were elevated in patients only after the work-related disability. Such findings suggest that clinicians treating these patients must be aware of the high prevalence of psychiatric disorders and be prepared to use mental health professionals to assist in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged pain disability in a substantial number of these patients.
    MeSH term(s) Adult ; Chronic Disease ; Comorbidity ; Female ; Humans ; Male ; Mental Disorders/epidemiology ; Middle Aged ; Musculoskeletal Diseases/epidemiology ; Musculoskeletal Diseases/psychology ; Occupational Diseases/epidemiology ; Occupational Diseases/psychology
    Language English
    Publishing date 2002-01-28
    Publishing country United States
    Document type Journal Article ; Research Support, U.S. Gov't, P.H.S.
    ZDB-ID 1223932-x
    ISSN 1536-5948 ; 1076-2752
    ISSN (online) 1536-5948
    ISSN 1076-2752
    DOI 10.1097/00043764-200205000-00014
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  8. Article ; Online: Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders.

    Dersh, Jeffrey / Mayer, Tom G / Gatchel, Robert J / Polatin, Peter B / Theodore, Brian R / Mayer, Eric A K

    Spine

    2008  Volume 33, Issue 20, Page(s) 2219–2227

    Abstract: Study design: Prospective outcomes study involving patients with chronic disabling occupational spinal disorders (CDOSD) diagnosed with (n = 199) or without (n = 1124) postinjury opioid-dependence disorder (ODD), based on the Diagnostic and Statistical ... ...

    Abstract Study design: Prospective outcomes study involving patients with chronic disabling occupational spinal disorders (CDOSD) diagnosed with (n = 199) or without (n = 1124) postinjury opioid-dependence disorder (ODD), based on the Diagnostic and Statistical Manual of Mental Disorders-fourth edition cirteria.
    Objective: To determine whether prescription opioid dependence, assessed at the beginning of rehabilitation treatment, is associated with poorer treatment outcomes in patients with CDOSDs attending an interdisciplinary rehabilitation program.
    Summary of background data: Controversy exists regarding the risk of iatrogenic ODD and treatment outcomes when long-term opioid therapy is used in the treatment of chronic nonmalignant pain conditions.
    Methods: A consecutive sample of patients with CDOSDs [n = 1323; mean (SD) length of disability = 18.8 (20.7) months] attending a tertiary referral center received intensive physical reactivation and pain/disability management interventions, based on a functional restoration model, including detoxification from opioids. One-year outcomes included return to work, work retention, healthcare utilization, new surgeries, recurrent injuries, and disability claim settlement.
    Results: Prevalence of ODD in this CDOSD population on entering the rehabilitation program was 15%. Even after adjusting for relevant demographic factors and comorbid psychiatric disorders, opioid-dependent patients were 1.7 times [95% confidence interval (CI): 1.0, 2.7] less likely to return to work, 2 times (95% CI: 1.3, 3.0) less likely to retain work at the 1-year interview, and 1.7 times (95% CI: 1.2, 2.5) more likely to engage in healthcare utilization from new providers, compared with nonopioid-dependent patients.
    Conclusions: Iatrogenic prescription opioid dependence may be a risk factor for less successful long-term work and health outcomes, even after detoxification from opioids as part of an interdisciplinary functional rehabilitation program. Chronic prescription opioid dependence in this patient population is also associated with a significantly higher prevalence of comorbid psychiatric conditions, both axis I and II.
    MeSH term(s) Adult ; Analgesics, Opioid/therapeutic use ; Disabled Persons ; Drug Prescriptions ; Female ; Humans ; Male ; Mental Disorders/complications ; Occupational Diseases/complications ; Occupational Diseases/drug therapy ; Opioid-Related Disorders/etiology ; Opioid-Related Disorders/rehabilitation ; Pain/drug therapy ; Pain/etiology ; Pain Measurement ; Patient Acceptance of Health Care ; Prospective Studies ; Sick Leave ; Spinal Injuries/complications ; Spinal Injuries/drug therapy
    Chemical Substances Analgesics, Opioid
    Language English
    Publishing date 2008-09-15
    Publishing country United States
    Document type Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/BRS.0b013e31818096d1
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  9. Article ; Online: A randomized clinical trial of treatment for lumbar segmental rigidity.

    Mayer, Tom G / Gatchel, Robert J / Keeley, Janice / McGeary, Don / Dersh, Jeffrey / Anagnostis, Christopher

    Spine

    2003  Volume 29, Issue 20, Page(s) 2199–205; discussion 2206

    Abstract: Study design: A randomized single-blind clinical trial of facet injections plus exercise, versus exercise alone, in chronic disabling work-related lumbar spinal disorders (CDWRLSD), accompanied by pilot interrater reliability and facet syndrome ... ...

    Abstract Study design: A randomized single-blind clinical trial of facet injections plus exercise, versus exercise alone, in chronic disabling work-related lumbar spinal disorders (CDWRLSD), accompanied by pilot interrater reliability and facet syndrome prevalence studies.
    Objectives: To systematically investigate the use of facet injections as an adjunct to supervised lumbar stretching exercises in regaining lumbar range of motion (ROM) following prolonged deconditioning after work-related lumbar injuries. To assess interrater reliability of visual assessment of segmental rigidity (SR), and to evaluate the prevalence of facet syndrome in cases of lumbar SR.
    Summary of background data: Corticosteroid joint injections have often been used to reduce musculoskeletal inflammation to facilitate joint mobilization in the presence of degenerative arthritis. Lumbar segmental rigidity is a recently described entity usually associated with painful chronic spinal disorders and postoperative spine surgery. Previous work has shown that SR and lumbar ROM improves with a brief intervention consisting of facet injections followed by specific stretching exercises. No systematic study has investigated the potential benefits of a combination of facet injections and exercise over supervised exercises alone to treat lumbar SR. Similarly, no study has assessed the association between SR and the facet syndrome.
    Methods: From a group of consecutive patients (n = 421) with CDWRLSD referred for tertiary rehabilitation between November 1999 and January 2001, 70 were noted to have SR on intake physical examination. The first part of this study assessed interrater reliability for detecting SR, and intrarater reliability for 3-segment true lumbar ROM measurements. Patients randomly assigned to participate in supervised stretching exercises with the addition of fluoroscopically guided bilateral facet injections at the involved levels (Group A, n = 36) also underwent facet syndrome prevalence assessment at the time of injection. They were compared to a randomly allocated comparison group (Group B, n = 34) undergoing exercises alone in a single-blind design. Physical therapists saw patients an average of twice per week, providing supervision of a progressive home stretching program. Inclinometric joint ROM was measured at the time of group allocation, and again 5 to 7 weeks later. Validated questionnaires of pain (intensity VAS) and disability (Million VAS) related to the CDWRLSD were provided before and after the interventions.
    Results: Part 1 reliability and facet syndrome prevalence work revealed that interrater reliability for experienced examiners to detect rigid segments was excellent (Pearson's r = 0.97, P < 0.01). Intrarater 3-joint motion measurement reliability was also good for all sagittal/coronal ROM (Pearson's r = 0.95-0.99, P < 0.01). Only 5 of 29 subjects with SR met criteria for facet syndrome (17%), consistent with prior prevalence studies of unselected patients with low back pain. In Part 2, a large majority of patients in both groups improved from the initial to the post-treatment ROM measurements (the primary outcome criterion of the study). However, a higher proportion of Group A (injection) patients (87%-95%) showed ROM improvement, compared to Group B (exercise only) patients (64%-79%). Group A patients showed a significantly greater ROM improvement in all sagittal and coronal movements, both in absolute terms and percent of initial measurement. No significant differences in pain or disability self-report were found between groups, pre- or postintervention, but both groups showed significant improvement from pre- to postintervention in pain and disability assessments.
    Conclusions: The detection of SR and measurement of 3-segment true lumbar ROM by experienced examiners is highly reliable. Only 17% of CDWRLSD patients with lumbar SR met criteria for the facet syndrome, a rate approximately equal to that of unselected low back pain cohorts. This indicates that lumbar SR may be found whether or not pain of facet joint origin is present. In the randomized trial, facet injections significantly increased the percentage of patients with SR showing ROM improvement, as well as the degree of improvement in lumbar mobility after treatment. There is no evidence that facet injections increase the improvements in pain/disability report noted in both groups.
    MeSH term(s) Adrenal Cortex Hormones/administration & dosage ; Adrenal Cortex Hormones/therapeutic use ; Adult ; Back Injuries/drug therapy ; Back Injuries/rehabilitation ; Combined Modality Therapy ; Delayed-Action Preparations ; Discitis/drug therapy ; Discitis/rehabilitation ; Discitis/surgery ; Diskectomy ; Exercise Therapy ; Female ; Fluoroscopy ; Humans ; Injections ; Lidocaine/administration & dosage ; Lidocaine/therapeutic use ; Lumbar Vertebrae ; Male ; Middle Aged ; Observer Variation ; Occupational Diseases/drug therapy ; Occupational Diseases/rehabilitation ; Pain Measurement ; Range of Motion, Articular ; Recovery of Function ; Single-Blind Method ; Syndrome ; Treatment Outcome ; Zygapophyseal Joint/physiopathology
    Chemical Substances Adrenal Cortex Hormones ; Delayed-Action Preparations ; Lidocaine (98PI200987)
    Language English
    Publishing date 2003-05-16
    Publishing country United States
    Document type Clinical Trial ; Comparative Study ; Journal Article ; Randomized Controlled Trial ; Research Support, N.I.H., Extramural ; Research Support, U.S. Gov't, P.H.S.
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/01.brs.0000142009.73869.8d
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  10. Article ; Online: Suicide-related behaviors in older patients with new anti-epileptic drug use: data from the VA hospital system.

    VanCott, Anne C / Cramer, Joyce A / Copeland, Laurel A / Zeber, John E / Steinman, Michael A / Dersh, Jeffrey J / Glickman, Mark E / Mortensen, Eric M / Amuan, Megan E / Pugh, Mary Jo

    BMC medicine

    2010  Volume 8, Page(s) 4

    Abstract: Background: The U.S. Food and Drug Administration (FDA) recently linked antiepileptic drug (AED) exposure to suicide-related behaviors based on meta-analysis of randomized clinical trials. We examined the relationship between suicide-related behaviors ... ...

    Abstract Background: The U.S. Food and Drug Administration (FDA) recently linked antiepileptic drug (AED) exposure to suicide-related behaviors based on meta-analysis of randomized clinical trials. We examined the relationship between suicide-related behaviors and different AEDs in older veterans receiving new AED monotherapy from the Veterans Health Administration (VA), controlling for potential confounders.
    Methods: VA and Medicare databases were used to identify veterans 66 years and older, who received a) care from the VA between 1999 and 2004, and b) an incident AED (monotherapy) prescription. Previously validated ICD-9-CM codes were used to identify suicidal ideation or behavior (suicide-related behaviors cases), epilepsy, and other conditions previously associated with suicide-related behaviors. Each case was matched to controls based on prior history of suicide-related behaviors, year of AED prescription, and epilepsy status.
    Results: The strongest predictor of suicide-related behaviors (N = 64; Controls N = 768) based on conditional logistic regression analysis was affective disorder (depression, anxiety, or post-traumatic stress disorder (PTSD); Odds Ratio 4.42, 95% CI 2.30 to 8.49) diagnosed before AED treatment. Increased suicide-related behaviors were not associated with individual AEDs, including the most commonly prescribed AED in the US - phenytoin.
    Conclusion: Our extensive diagnostic and treatment data demonstrated that the strongest predictor of suicide-related behaviors for older patients newly treated with AED monotherapy was a previous diagnosis of affective disorder. Additional, research using a larger sample is needed to clearly determine the risk of suicide-related behaviors among less commonly used AEDs.
    MeSH term(s) Aged ; Aged, 80 and over ; Anticonvulsants/adverse effects ; Anticonvulsants/therapeutic use ; Case-Control Studies ; Comorbidity ; Databases, Factual ; Female ; Hospitals, Veterans ; Humans ; International Classification of Diseases ; Logistic Models ; Male ; Mental Disorders/drug therapy ; Phenytoin/adverse effects ; Phenytoin/therapeutic use ; Reproducibility of Results ; Suicide/statistics & numerical data ; United States
    Chemical Substances Anticonvulsants ; Phenytoin (6158TKW0C5)
    Language English
    Publishing date 2010-01-11
    Publishing country England
    Document type Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
    ISSN 1741-7015
    ISSN (online) 1741-7015
    DOI 10.1186/1741-7015-8-4
    Database MEDical Literature Analysis and Retrieval System OnLINE

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