An analysis of the components of pain, function, and health-related quality of life in patients with failed back surgery syndrome treated with spinal cord stimulation or conventional medical management

Objectives: Failed back surgery syndrome (FBSS) patients experience pain, functional disability, and reduced health-related quality of life (HRQoL) despite anatomically successful surgery. Examining sub-dimensions of health outcomes measures provides insight into patient well-being. Materials and Methods: The international multicenter PROCESS trial collected detailed HRQoL (EuroQol-5D; Short-Form 36) and function (Oswestry Disability Index) information on 100 FBSS patients. Results: At baseline, patients reported moderate-to-severe leg and back pain adversely affecting all dimensions of function and HRQoL. Compared with conventional medical management alone, patients also receiving spinal cord stimulation (SCS) reported superior pain relief, function, and HRQoL at six months on overall and most sub-component scores. The majority of these improvements with SCS were sustained at 24 months. Nonetheless, 36-40% of patients experienced ongoing marked disability (standing, lifting) and HRQoL problems (pain/discomfort). Conclusions: Longer-term patient management and research must focus on these refractory FBSS patients with persisting poor function and HRQoL outcomes.

Douleurs neuropathiques : quelques pistes pour une évaluation structurée et une prise en charge spécifique et globale [Neuropathic pain: tips and tools for specific and comprehensive pain management]

Les syndromes neuropathiques sont caractérisés par une douleur d'intensité élevée, de longue durée et résistante aux analgésiques classiques. De fait, il existe un risque important de répercussions sur la vie et le bien-être des patients. A travers une vignette clinique, cet article abordera le diagnostic, le traitement spécifique et l'impact de la douleur neuropathique sur la qualité de vie et les conséquences psychologiques associées, comme la dépression et l'anxiété. Nous présenterons des outils validés qui permettent d'objectiver la composante neuropathique aux douleurs et les comorbidités psychiatriques associées. Cette évaluation globale favorise un meilleur dialogue avec les patients ainsi que l'élaboration de stratégies thérapeutiques, notamment par le biais d'antidépresseurs, dont l'efficacité sera discutée en fin d'article. Neuropathic pain syndromes are characterized by intense and long lasting pain that is resistant to usual analgesics. Patients are therefore at high risk of decreased quality of life and impaired well-being. Using a case report, we will consider in this article the diagnosis and treatment of neuropathic pain as well as its impact on the quality of life including psychological consequences such as depression and anxiety. We will present simple and reliable scales that can help the general practitioner evaluate the neuropathic component of the pain syndrome and its related psychiatric co-morbidities. This comprehensive approach to pain management should facilitate communication with the patient and help the practitioner select the most appropriate therapeutic strategy, notably the prescription of antidepressants, the efficacy of which we will discuss at the end of the article.

Patterns of pain freedom response in 497 cases with classical trigeminal neuralgia and at least one year of follow-up treated by gamma knife radiosurgery

Purpose: To identify patterns of initially pain freedom response in patients with classical trigeminal neuralgia (CTN) with Gamma Knife surgery (GKS) and to compare their associated hypoesthesia and recurrence rates. Methods: In this study we analysed only 497 patients treated between July 1992 and November 2010, with a follow-up longer than 1 year, after excluding megadolichobasilar artery and multiple sclerosis related trigeminal neuralgia, as well as the second GKS treatments so as to have only cases with CTN and single radiosurgical treatment. GKS using a Gamma Knife (model B or C or Perfexion) was performed, based on both MRI and computer tomography (CT) targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.8 mm (range 4.5-14) anteriorly to the emergence of the nerve. A median maximum dose of 85 Gy (range 70-90) was delivered. After empiric methods but also by using a chart with clear cut-off periods of pain free distribution, we were able to divide the initially pain free patients into 3 separate groups: within the first 48 hours, after 48 hours till 30 days and after 30 days, respectively. Results: The median follow- up period was 43.75 months (range 12-174.41). Four hundred and fifty-four patients (91.75%) were initially pain free in a median time of 10 days (range 1-459): 169 (37.2%) became pain free within the first 48 hours (pf<=48 h), compared to 194 (42.8%) between the 3-rd day and the day 30 (pf (>48 h, <=30 d)), inclusively and 91 (20%) patients after 30 days (pf>30d). Differences in terms of postoperative hypoesthesia were found with a p value of 0.014 as follows: the group pf<=48 h had 18 (13.7%) compared to pf (>48 h, <=30 d) with 30 (19%) and pf>30d with 22 (30.5%) patients developing a postoperative GKS hypoesthesia. One hundred and fifty seven (34.4%) patients initially pain free experienced a recurrence with a median delay of 24 months (range 0.62-150.06). There were no statistically significant differences between the three groups concerning recurrence (p value of 0.515). Conclusions: An important number of patients (169 cases, 37.2%) became pain free in the first 48 hours. Hypoesthesia rate was higher within the group becoming pain free after 30 days with a statistically significant difference between the three populations (p= 0.014). Further analysis will eventually help to elucidate the differences observed among groups.

Control de accesos mediante reconocimiento facial

En esta memoria expone el trabajo que se ha llevado a cabo para intentar crear un sistema de reconocimiento facial.

Anatomic and functional outcome after 23-gauge sutureless transconjunctival vitrectomy, peeling and intravitreal triamcinolone for idiopathic macular epiretinal membranes

Purpose:To report the functional, anatomic outcome and safety profile of 23-gauge pars plana vitrectomy (PPV) combined with peeling and intravitreal injection of triamcinolone acetonide (TA) in eyes with idiopathic epiretinal membranes (ERM). Methods:Retrospective, nonrandomized study of consecutive patients who underwent 23-gauge transconjunctival sutureless PPV with subsequent membrane peeling and intravitreal TA injection for an idiopathic ERM. All patients were operated between February 2007 and February 2008 at the Jules Gonin University Eye Hospital. The minimum follow-up was 6-months. Results:Thirty-nine eyes of 39 patients were included. The mean follow-up was 7 months (SD: 2.2, range: 6-15 months). Twenty-two (56%) eyes were pseudophakic and 17 (44%) were phakic at the time of surgery. Mean preoperative intraocular pressure (IOP) was 14 mmHg (SD: 3.5). At the final follow-up mean IOP was 14.5 (SD: 2.7) that did not differ significantly from the IOP at baseline (P: 0.14- 2-tailed t test). Five patients (13%) needed temporary topical anti-glaucoma treatment.Mean preoperative BCVA was 0.28 decimal equivalent (logMAR 0.54, SD: 0.2, range: 1.0 - 0.2). and improved significantly (P <0.0001, 2-tailed t test) to a mean of 0.6 decimal equivalent (logMAR 0.22, SD: 0.16, range: 0.6 - 0) at the final follow-up. The visual acuity improved by a mean of 3.2 lines (SD 2.1, range 0- 8). Twenty-nine patients (74%) demonstrated a gain of 3 or more lines.Mean central macular thickness (CMT) was 456 µm (SD: 77) at the baseline that reduced significantly (P <0.0001, 2-tailed t test) at the final follow-up to 327µm (SD: 79). Average CMT reduction was 131µm (SD: 77, range: 36- 380 µm). A subgroup analysis of 15 selected cases that had CMT measurement 1 week after surgery demonstrated that 84% of the total final reduction in CMT occurred during the first week. Conclusions:23-gauge sutureless transconjunctival vitrectomy with the concomitant administration of intravitreal TA is a safe and effective technique for the treatment of idiopathic ERM and may speed up anatomical recovery.

A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain.

OBJECTIVES: We studied the value of ultrasound (US) to define shoulder pathology and guide local steroid injection in comparison with a standard injection in the management of the acute painful shoulder. METHODS: Seventy consecutive patients with acute shoulder pain were assessed clinically and by US. Patients were randomized to receive either a standard subacromial infiltration of 7 mg of betamethasone or a US-guided injection according to the US diagnosis. Follow-up evaluations were performed by an independent assessor who was blinded to the results of the initial US and clinical assessments. RESULTS: Sixty-seven patients completed the study. Both groups showed a significant reduction in both daytime and night pain compared to baseline. The US injection group had significantly less pain at rest at 2 and 6 weeks (NRS: 1.6 vs 3.3, P<0.005; 3 vs 4.2, P<0.04). The percentage of good responders was significantly higher in US group at 2 weeks, (81% vs 54%, P<0.005) and 6 weeks (64% vs 38%, P<0.05). At 2 and 6 weeks, responder rate and activity pain scores as well as Constant score were in favour of US, though did not reach statistical significance. CONCLUSION: Local steroid injection for shoulder pain leads to significant improvements in pain and function for up to 12 weeks. An US examination to define the origin of shoulder pain as well as to guide injection provides significant additional benefits for up to 6 weeks. We recommend routine US examination as part of the management of acute shoulder pain.

Local delivery of glial cell line-derived neurotrophic factor improves facial nerve regeneration after late repair.

OBJECTIVES/HYPOTHESIS: Facial nerve regeneration is limited in some clinical situations: in long grafts, by aged patients, and when the delay between nerve lesion and repair is prolonged. This deficient regeneration is due to the limited number of regenerating nerve fibers, their immaturity and the unresponsiveness of Schwann cells after a long period of denervation. This study proposes to apply glial cell line-derived neurotrophic factor (GDNF) on facial nerve grafts via nerve guidance channels to improve the regeneration. METHODS: Two situations were evaluated: immediate and delayed grafts (repair 7 months after the lesion). Each group contained three subgroups: a) graft without channel, b) graft with a channel without neurotrophic factor; and c) graft with a GDNF-releasing channel. A functional analysis was performed with clinical observation of facial nerve function, and nerve conduction study at 6 weeks. Histological analysis was performed with the count of number of myelinated fibers within the graft, and distally to the graft. Central evaluation was assessed with Fluoro-Ruby retrograde labeling and Nissl staining. RESULTS: This study showed that GDNF allowed an increase in the number and the maturation of nerve fibers, as well as the number of retrogradely labeled neurons in delayed anastomoses. On the contrary, after immediate repair, the regenerated nerves in the presence of GDNF showed inferior results compared to the other groups. CONCLUSIONS: GDNF is a potent neurotrophic factor to improve facial nerve regeneration in grafts performed several months after the nerve lesion. However, GDNF should not be used for immediate repair, as it possibly inhibits the nerve regeneration.

Psychometric characteristics of the Spanish version of instruments to measure neck pain disability

BACKGROUND. The NDI, COM and NPQ are evaluation instruments for disability due to NP. There was no Spanish version of NDI or COM for which psychometric characteristics were known. The objectives of this study were to translate and culturally adapt the Spanish version of the Neck Disability Index Questionnaire (NDI), and the Core Outcome Measure (COM), to validate its use in Spanish speaking patients with non-specific neck pain (NP), and to compare their psychometric characteristics with those of the Spanish version of the Northwick Pain Questionnaire (NPQ). METHODS. Translation/re-translation of the English versions of the NDI and the COM was done blindly and independently by a multidisciplinary team. The study was done in 9 primary care Centers and 12 specialty services from 9 regions in Spain, with 221 acute, subacute and chronic patients who visited their physician for NP: 54 in the pilot phase and 167 in the validation phase. Neck pain (VAS), referred pain (VAS), disability (NDI, COM and NPQ), catastrophizing (CSQ) and quality of life (SF-12) were measured on their first visit and 14 days later. Patients' self-assessment was used as the external criterion for pain and disability. In the pilot phase, patients' understanding of each item in the NDI and COM was assessed, and on day 1 test-retest reliability was estimated by giving a second NDI and COM in which the name of the questionnaires and the order of the items had been changed. RESULTS. Comprehensibility of NDI and COM were good. Minutes needed to fill out the questionnaires [median, (P25, P75)]: NDI. 4 (2.2, 10.0), COM: 2.1 (1.0, 4.9). Reliability: [ICC, (95%CI)]: NDI: 0.88 (0.80, 0.93). COM: 0.85 (0.75,0.91). Sensitivity to change: Effect size for patients having worsened, not changed and improved between days 1 and 15, according to the external criterion for disability: NDI: -0.24, 0.15, 0.66; NPQ: -0.14, 0.06, 0.67; COM: 0.05, 0.19, 0.92. Validity: Results of NDI, NPQ and COM were consistent with the external criterion for disability, whereas only those from NDI were consistent with the one for pain. Correlations with VAS, CSQ and SF-12 were similar for NDI and NPQ (absolute values between 0.36 and 0.50 on day 1, between 0.38 and 0.70 on day 15), and slightly lower for COM (between 0.36 and 0.48 on day 1, and between 0.33 and 0.61 on day 15). Correlation between NDI and NPQ: r = 0.84 on day 1, r = 0.91 on day 15. Correlation between COM and NPQ: r = 0.63 on day 1, r = 0.71 on day 15. CONCLUSION. Although most psychometric characteristics of NDI, NPQ and COM are similar, those from the latter one are worse and its use may lead to patients' evolution seeming more positive than it actually is. NDI seems to be the best instrument for measuring NP-related disability, since its results are the most consistent with patient's assessment of their own clinical status and evolution. It takes two more minutes to answer the NDI than to answer the COM, but it can be reliably filled out by the patient without assistance. TRIAL REGISTRATION Clinical Trials Register NCT00349544.

Validity and reliability of the Spanish version of the DN4 (Douleur Neuropathique 4 questions) questionnaire for differential diagnosis of pain syndromes associated to a neuropathic or somatic component

BACKGROUND This study assesses the validity and reliability of the Spanish version of DN4 questionnaire as a tool for differential diagnosis of pain syndromes associated to a neuropathic (NP) or somatic component (non-neuropathic pain, NNP). METHODS A study was conducted consisting of two phases: cultural adaptation into the Spanish language by means of conceptual equivalence, including forward and backward translations in duplicate and cognitive debriefing, and testing of psychometric properties in patients with NP (peripheral, central and mixed) and NNP. The analysis of psychometric properties included reliability (internal consistency, inter-rater agreement and test-retest reliability) and validity (ROC curve analysis, agreement with the reference diagnosis and determination of sensitivity, specificity, and positive and negative predictive values in different subsamples according to type of NP). RESULTS A sample of 164 subjects (99 women, 60.4%; age: 60.4 +/- 16.0 years), 94 (57.3%) with NP (36 with peripheral, 32 with central, and 26 with mixed pain) and 70 with NNP was enrolled. The questionnaire was reliable [Cronbach's alpha coefficient: 0.71, inter-rater agreement coefficient: 0.80 (0.71-0.89), and test-retest intra-class correlation coefficient: 0.95 (0.92-0.97)] and valid for a cut-off value > or = 4 points, which was the best value to discriminate between NP and NNP subjects. DISCUSSION This study, representing the first validation of the DN4 questionnaire into another language different than the original, not only supported its high discriminatory value for identification of neuropathic pain, but also provided supplemental psychometric validation (i.e. test-retest reliability, influence of educational level and pain intensity) and showed its validity in mixed pain syndromes.

Traitement des fibroses pulmonaires idiopathiques [Treatment of idiopathic pulmonary fibrosis]

Idiopathic pulmonary fibrosis still has to be diagnosed by elimination. Neoplasm, toxic treatments, collagen vascular disease, professional exposure or diagnosis such as sarcoidosis have to be ruled out. The repercussions on gas exchange are the most reliable indications of the severity of the disease, the pulmonary function test or chest x-rays alone being often misleading. Transbronchic biopsies, thoracotomy or thoracoscopies provide a precise diagnosis. In many cases only broncho-alveolar lavage and a high resolution CT-scan are performed to rule out infection or tumor and to assess the inflammatory state of the disease. Due to the often poor prognosis of this disease and its often poor response to steroids, the role of cytostatic drugs, cyclosporine and colchicine, and of pulmonary graft is discussed.

Lung function in idiopathic pulmonary fibrosis--extended analyses of the IFIGENIA trial.

BACKGROUND The randomized placebo-controlled IFIGENIA-trial demonstrated that therapy with high-dose N-acetylcysteine (NAC) given for one year, added to prednisone and azathioprine, significantly ameliorates (i.e. slows down) disease progression in terms of vital capacity (VC) (+9%) and diffusing capacity (DLco) (+24%) in idiopathic pulmonary fibrosis (IPF). To better understand the clinical implications of these findings we performed additional, explorative analyses of the IFGENIA data set. METHODS We analysed effects of NAC on VC, DLco, a composite physiologic index (CPI), and mortality in the 155 study-patients. RESULTS In trial completers the functional indices did not change significantly with NAC, whereas most indices deteriorated with placebo; in non-completers the majority of indices worsened but decline was generally less pronounced in most indices with NAC than with placebo. Most categorical analyses of VC, DLco and CPI also showed favourable changes with NAC. The effects of NAC on VC, DLco and CPI were significantly better if the baseline CPI was 50 points or lower. CONCLUSION This descriptive analysis confirms and extends the favourable effects of NAC on lung function in IPF and emphasizes the usefulness of VC, DLco, and the CPI for the evaluation of a therapeutic effect. Most importantly, less progressed disease as indicated by a CPI of 50 points or lower at baseline was more responsive to therapy in this study.

Factors influencing interprofessional practices of physiotherapists working in private settings with people with low back pain: a qualitative study

Purpose: Collaboration and interprofessional practices are highly valued in health systems everywhere, partly based on the rationale that they improve outcomes of care for people with complex health problems, such as low back pain. Research in the area of low back pain also supports the involvement of different health professionals in the interventions for people who present this condition. The aim of this studywas to identify factors influencing the interprofessional practices of physiotherapists working in private settings with people with low back pain. Relevance: Physiotherapists, like other health professionals, are encouraged to engage in interprofessional practices in their dailywork. However, to date, very little is known of their interprofessional practices, especially in private settings. Understanding physiotherapists' interprofessional practices and their influencing factors will notably advance knowledge relating to the organisation of physiotherapy services for people with low back pain. Participants: Participants in this study were 13 physiotherapists including 10 women and 3 men, having between 3 and 22 years of professional experience, and working in one of 10 regions of the Province of Quebec (Canada). In order to obtain maximal variation in the perspectives, participants were selected using a recruitment matrix including three criteria: duration of professional experience, work location, and physical proximity with other professionals. Methods: Thiswas a descriptive qualitative study using faceto- face semi-structured interviews as the main method of data collection. An interview guide was developed based on an evidence-derived frame of reference. Each interview lasted between 55 and 95 minutes and was transcribed verbatim. Analysis: Qualitative analyses took the form of content analysis, encompassing data coding and general thematic regrouping. NVivo version 8 was used to assist data organisation and analysis. Results: Multiple factors influencing the interprofessional practices of physiotherapists were identified. The main factors include the consulting person's health condition, the extent of knowledge on health professionals' roles and fields of practice, the proximity and availability of professional resources, as well as daily work schedules. Conclusions: Our findings highlight the influence of multiple factors on physiotherapists' interprofessional practices, including professional practice and organisational issues. However, further research on the interprofessional practices of physiotherapists is still required. Research priorities targeting the views of other health professionals, as well as those of services users, would enhance our comprehension of interprofessional practices of physiotherapists. Implications: This study provides new insights that improve our understanding of the interprofessional practices of physiotherapists working in private settings with people with low back pain, more specifically on the factors influencing these practices. Based on our findings, implementing changes such as improving current and future health professionals' knowledge of the fields and roles of other health professionals through training may contribute to positively influencing interprofessional practices. Keywords: Interprofessional practices; Private practice; Low back pain Funding acknowledgements: This research was supported in part by a B.E. Schnurr Memorial Fund Research Grant administered by the Physiotherapy Foundation of Canada, as well as from a clinical research partnership in physiotherapy between the Quebec Rehabilitation Research Network (REPAR) and the Ordre professionnel de la physiothérapie du Québec (OPPQ). KP received doctoral-level scholarships from the Canadian Institutes of Health Research (CIHR) and the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST). CE Dionne is a FRSQ senior Research Scholar. Ethics approval: This project was approved by the ethics research committee of the Institut de réadaptation en déficience physique de Québec.