Telerehabilitation Found Effective for Low Back Pain Relief

PainRelief.com Interview with:
Mark W Werneke, PT, MS, Dip. MDT
Net Health Systems, Inc.
Pittsburgh PA

Mark W Werneke

PainRelief.com:  What is the background for this study? 

Response: Coronavirus pandemic (COVID-19) has had a profound effect on changing health care delivery systems and resulted in a rapid growth of telerehabilitation care models. In addition, patients experiencing chronic low back pain increased during the pandemic which was confounded by mandatory lockdowns and lack of physical activity. There is scant literature demonstrating telerehabilitation’s effectiveness and efficiency for patients with low back pain seeking rehabilitation services during COVID-19 pandemic compared to traditional in-person office visit care.

The primary aim of our study was to examine the association between telerehabilitation treatments administered during every day clinical practice and functional status, number of visits, and patient satisfaction with treatment result outcomes compared to in-person care observed during the height of the pandemic. Using Focus on Therapeutic Outcomes (FOTO) database, our sample consisted of 91,117 episodes of care from 1,398 clinics located in 46/50 US states. Propensity score matching analytics was used to match episodes of care with or without telerehabilitation and standardized differences (S-D) were used to assess whether successful matching between telerehabilitation and no-telerehabilitation subgroups allowed for valid outcome comparisons.

Study Evaluates Complex Relationship Between Eating and Chronic Pain

PainRelief.com Interview with:
Paul Geha, M.D
Assistant Professor of Psychiatry
University of Rochester Medical Center
Rochester, NY 14620

Dr. Geha

PainRelief.com:  What is the background for this study? 

Response: Chronic pain and obesity are interrelated; chronic pain is more common in obese individuals and obese individuals have a higher occurrence of chronic pain conditions such as low-back pain.  The mechanisms behind this association are poorly understood.  In this line of work we are trying to offer an explanation for how chronic pain could lead to obesity. 

We build on two previous facts established in the literature to come up with a new theory. 

First, it is well known that the current obesity epidemic is due to overeating in an environment where highly caloric food is cheap and readily available (e.g., fast food).

Second, our brain imaging research on chronic pain patients established that chronic pain affects the brain motivational pathways (or emotional brain) which are directly involved in feeding decisions, especially the ones that come after satiety.  As such, the emotional brain has been implicated in the decision to overeat on top of satiety. We therefore hypothesized that chronic pain would be associated with disrupted eating behavior that could lead to overeating because of changes in the emotional brain of patients. This is a new approach because the prior thinking posited that obesity and chronic pain are interrelated either because of increased inflammation originating from the increased fat mass or from the fear of movement that patients may have leading to a more sedentary lifestyle. While both theories may be correct, they have never been confirmed.

The current paper builds on a finding we published in PAIN 2014 where we established disrupted eating behavior in patients with chronic low-back pain affecting mainly high-fat foods but not sugary drinks.  In that work we asked patients with long-standing history of chronic low-back pain to sample without consumption pudding with increasing concentration of fat and a sugary drink with increasing concentration of sucrose.  While the sensory experience of the food items was normal in the patients, they reported less pleasure (“liking”) from tasting the fatty pudding but not the sugary drink. On a different session, we brought back the patients and offered them to consume as much as they wanted the pudding that they liked the most during the first testing session. Participants were asked to come hungry.   Chronic back-pain patients showed that their liking and hunger ratings did not predict how much they ate.  Healthy controls showed a linear relationship between liking and hunger ratings and how much they ate. 

In the manuscript we just published in PLOS One we continued this line of work to understand how this disrupted eating behavior sets in as low-back pain develops or subsides.  We wanted to know whether disrupted eating behavior develops in conjunction with chronic pain or because of it.  Hence, we recruited patients with new onset low-back pain (6-12 weeks duration) and tested them in the same way described in our PAIN 2014 paper at baseline and then again at one year as some of them recovered from pain while others became chronic low-back pain because pain persisted at one year follow-up.  In this manuscript we also collected brain images that would allow-us to measure volumes of a key structure in the emotional brain, the nucleus accumbens.  The function of the latter structure is to translate our motivation (e.g., wanting to eat) to actions (e.g. the motor response needed to reach for the food). We wanted to know whether we can link the disrupted eating behavior to measures in the emotional brain. This question was based on our previous finding where we observed that patients at risk of becoming chronic pain or patients already in the chronic phase have a compromised accumbens (i.e. smaller than normal).

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As Opioid Prescriptions Fall, Alternate Prescriptions for Pain Relief Increase

PainRelief.com Interview with:
Lauren R. Gorfinkel MPH
New York State Psychiatric Institute
New York, NY
Department of Medicine, University of British Columbia
Vancouver, Canada

PainRelief.com:  What is the background for this study? 

Response: The opioid crisis has led to clear declines in opioid prescribing across North America, however, chronic pain remains an extremely common health problem with limited treatment options. This study was therefore interested in using nationally-representative data to find out whether alternative pain medications are growing more popular as opioid prescriptions decline.

NEJM: Study Recommends Hip Implants Be Fixed with Bone Cement

PainRelief.com Interview with:
Matthew Costa
Professor of Orthopaedic Trauma Surgery
University of Oxford 
Honorary Consultant Trauma Surgeon
John Radcliffe Hospital, Oxford

Dr. Costa

PainRelief.com:  What is the background for this study? 

Response: The number of patients sustaining a fracture of the hip is increasing rapidly as patients all around the world live into older age. It estimated there will be over 6 million hip fractures by 2050. Approximately half of hip fractures occur at the neck of the thigh bone (femur) and the majority of patients over 60 years with such a fracture are treated with a partial hip replacement in which the head of the femur is replaced with a metal implant (hemiarthroplasty).

There is controversy about how best to fix the hemiarthroplasty implant to the bone of the femur. If the implant is not securely bonded to the patient’s bone it can loosen causing pain and restricting movement and activities of daily living. This study was about the best way to fix the implant to the patient’s bone.

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Many Young Adults and Adolescents Vape Both Tobacco and Cannabis

PainRelief.com Interview with:
Ruoyan Sun PhD
Assistant Professor
School of Public Health
The University of Alabama at Birmingham

PainRelief.com:  What is the background for this study? 

Response: Many people consider vaping as just nicotine vaping, but these vaping devices can be used to vape cannabis as well. We are curious about how many e-cigarette users are vaping cannabis. Using the Population Assessment of Tobacco and Health (PATH) study from 2018 to 2019, we investigated the proportion of current (past 30-day) e-cigarette users (ages 12-24) who vaped cannabis and their frequency of cannabis vaping.  

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Identification of the Muscle-Relaxant Carisoprodol (Soma) and Non-Controlled Prescription Substances in Drug-Arrests

PainRelief.com Interview with:
Maaz Siddiqui, BS
Department of Medical Education
Geisinger Commonwealth School of Medicine
Scranton, Pennsylvania

Maaz Siddiqui

PainRelief.com: What is the background for this study?

Response: Over the last twenty years, the rise of deaths due to drug overdoses have been mainly and rightfully attributed to opioids. However, many investigations identify non-opioid drugs and drug classes that additionally contribute to deaths due to polysubstance overdoses. Through the Maine Diversion Alert Program (DAP) data, we examined drugs that often escape the attention of healthcare providers and directly or indirectly contribute to substance misuse, arrests, addiction, and deaths due to overdose.

The goal of this study was to utilize a novel dataset to uncover and identify the noncontrolled drugs that have shown potential to be misused.

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About 1/3 North Americans Self Medicate with Cannabis, Mostly for Pain

PainRelief.com Interview with:
Janni Leung, PhD
Senior Research Fellow
National Centre for Youth Substance Use Research (NCYSUR)
The University of Queensland

Dr. Leung

PainRelief.com:  What is the background for this study? 

Response: There is increasing interest in cannabis use for medical reasons, and we want to find out how many people are using it and for what.

PainRelief.com:  What are the main findings?

Response: Almost 1 in 3 of North Americans self-reported that they have used cannabis for medical reasons, with higher use reported by young adults, although chronic conditions are less prevalent in this group.

Most common reasons were to help with pain, sleep, depression and anxiety, but some reported using it to manage their drug or alcohol use and psychosis.

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More Kids Poisoned by Cannabis Since Legalization

PainRelief.com Interview with:
Daniel Myran, MD, MPH, CCFP, FRCPC
Family and Public Health and Preventive Medicine Physician 
CIHR Fellow, Ottawa Hospital Research Institute 
Department of Family Medicine Innovation Fellow
University of Ottawa 

Dr. Myran

PainRelief.com:  What is the background for this study? 

Response: Canada legalized recreational, or non-medical, cannabis in October 2018. Canada took phased approach to legalization initially only allowing flower-based cannabis products and oils and after one year permitting the sale of commercial cannabis edibles (e.g. THC containing candies, baked goods, and drinks). In this study we took advantage of this phased roll out of legal cannabis to understand the impact of legalization on cannabis exposures or poisonings in children aged 0-9 years and the contribution of different types of cannabis products to these events. 

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Risk of AMA Hospital Discharge High Among Patient with Opioid-Related Conditions

PainRelief.com Interview with:
Peggy Compton, RN, PhD, FAAN
Professor and van Ameringen Endowed Chair
Program Director, Hillman Scholars in Nursing Innovation
Department of Family and Community Health
University of Pennsylvania School of Nursing
Philadelphia, PA 19104

Dr. Compton

PainRelief.com:  What is the background for this study? 

Response: Patients with substance use disorders are highly likely to leave the hospital against medical advice (AMA) or self-discharge, putting them at risk for poorer health outcomes including progressing illness, readmissions, and even death. Inadequate pain management is identified as a potential motivator of self-discharge in this patient population.  The objective of these secondary analyses was to describe the association between acute and chronic pain and AMA discharges among persons with opioid-related conditions.

PainRelief.com:  What are the main findings?

Response: The main findings were that 16% of the 7,972 admissions involving opioid-related conditions culminated in an AMA discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to have an AMA discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. 

PainRelief.com: What should readers take away from your report?

Response: These findings underscore the importance of aggressive and effective pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.  

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: Future research should be aimed at evaluating approaches for effective pain management in patients with opioid related disorders.  These patients may present with high levels of opioid analgesic tolerance and opioid-induced hyperalgesia, suggesting that non-opioid analgesic approaches may be warranted to effectively manage their pain.  Regardless of the specific pain management approach employed, patients with opioid-related disorders should believe that their complaints of pain are taken seriously and managed aggressively to maximize duration of hospital stay.

Citation:

Compton, P., Aronowitz, S.V., Klusaritz, H. et al. Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study. Harm Reduct J 18131 (2021). https://doi.org/10.1186/s12954-021-00581-6

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Acupuncture for Pain Relief: Insurance Coverage Increasing But Most Still Self Pay

PainRelief.com Interview with:
Molly Candon, PhD
Research Assistant Professor, Center for Mental Health, Department of Psychiatry
Assistant Professor, Department of Health Care Management
Director, Associate Fellows Program, Leonard Davis Institute of Health Economics
Perelman School of Medicine and the Wharton School
University of Pennsylvania

Molly Candon, PhD Research Assistant Professor, Center for Mental Health, Department of Psychiatry Assistant Professor, Department of Health Care Management Director, Associate Fellows Program, Leonard Davis Institute of Health Economics Perelman School of Medicine and the Wharton School University of Pennsylvania
Dr. Candon

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Insurance design for pain care, including whether treatments are covered and how generously they are covered, is an important element of access and adherence. Acupuncture therapy is a safe and evidence-based treatment for numerous pain conditions, and our team was curious if acupuncture coverage has changed in recent years given the need for non-opioid treatments during the ongoing opioid epidemic. 

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