Naloxone-Prescribing Practices in a Freestanding Rehabilitation Hospital.

OBJECTIVE: The study aims to determine whether Physical Medicine & Rehabilitation physicians offer naloxone per the Centers for Disease Control and Prevention Guidelines to patients at the highest risk of complications from opioid treatment and whether there is a difference between inpatient and outpatient naloxone prescribing. DESIGN: A retrospective chart review on 389 adults (outpatient n = 166; inpatient n = 223) from May 4 to May 31, 2022, at an academic rehabilitation hospital. Prescribed medications and comorbidities were evaluated to determine whether Centers for Disease Control and Prevention criteria for offering naloxone were met and whether naloxone was offered. RESULTS: One hundred twenty-nine opioid prescriptions were written for 102 outpatients; 61 qualified for naloxone (morphine milliequivalent range = 10-1080, mean = 158.08). On inpatient, 68 patients received 86 opioid prescriptions; 35 qualified for naloxone (morphine milliequivalent range = 3.75-246, mean = 62.36). Overall, there was a significantly lower rate of opioid prescriptions for inpatients (30.49%) than outpatients (61.45%) ( P < 0.0001), a nonsignificant lower rate of inpatient (51.47%) than outpatient (59.80%) "at-risk" prescriptions ( P = 0.351), and a weakly significant lower rate of naloxone prescribing for inpatient (2.86%) than outpatient visits (8.20%) ( P < 0.0519). CONCLUSIONS: At this rehabilitation hospital, there was a low rate of naloxone prescribing by inpatient and outpatient providers, with a higher rate occurring in the outpatient than inpatient setting. More research is needed to understand this prescribing trend to determine potential interventions.

Comparison of Pain Score Reduction Using Triamcinolone vs. Betamethasone in Transforaminal Epidural Steroid Injections for Lumbosacral Radicular Pain.

OBJECTIVE: Although the comparative efficacy of particulate vs. nonparticulate steroids for the treatment of radicular pain with transforaminal epidural steroid injection has been investigated, there is minimal literature comparing particulate steroids. The authors aimed to determine whether transforaminal epidural steroid injection with triamcinolone or betamethasone, two particulate corticosteroids, more effectively reduces lumbosacral radicular pain. DESIGN: This is a longitudinal cohort study of 1021 patients (1568 transforaminal epidural steroid injections) who received betamethasone or triamcinolone between January 2006 and October 2007 in an academic spine center. The frequency of greater than 50% pain reduction was compared between groups. RESULTS: This study included 42.4% (433) male and 57.6% (588) female patients, with a mean (SD) age of 54.1 (16.7) yrs. Betamethasone and triamcinolone were used in 78.8% (1235) and 21.2% (333) of subjects, respectively. Significantly more patients who received triamcinolone (44.4% [95% confidence interval, 36.2%-52.8%]) experienced greater than 50% pain reduction at short-term follow-up (1-4 wks) compared with patients who received betamethasone (26.8% [95% confidence interval, 22.7%-31.4%]). CONCLUSIONS: Patients who received transforaminal epidural steroid injection with triamcinolone reported more frequent pain relief of greater than 50% at short-term follow-up compared with those who received betamethasone. These findings further develop the literature on comparative effectiveness in epidural steroid injections. However, given the exploratory and retrospective nature of this investigation, further study is needed.

Concordant pain provocation during transforaminal epidural steroid injection for lumbosacral radiculopathy: effect on pain outcome and predictive factors.

BACKGROUND: Anecdotal report suggests that provocation of pain during epidural steroid injection (ESI) that is concordant with typical radicular symptoms predicts pain outcome following injection. However, limited evidence exists that substantiates this theory. Additionally, there is a paucity of literature investigating factors associated with the provocation of pain during ESI. OBJECTIVES: The goal of this study was to determine whether provocation of concordant radicular pain during transforaminal ESI predicts pain relief immediately after injection and at short-term follow-up. Demographic, radiologic, and procedural factors associated with the pain provocation and pain outcomes at immediate and short-term follow-up were also investigated. STUDY DESIGN: Longitudinal cohort study. SETTING: Urban academic outpatient interventional spine clinics. METHODS: Adults who underwent a fluoroscopically guided transforaminal ESI without sedation between January 1, 2006, and October 29, 2007, for the treatment of lumbosacral radicular pain were included in this study. The relationships between provocation of concordant pain, immediate post-injection, and follow-up visual analogue scale (VAS) pain scores, as well as with demographic, radiologic, and procedural factors were determined using chi-square/Fisher's exact tests for categorical variables and t-tests or ANOVA for numerical variables. RESULTS: One thousand twenty one patients, 42.4% (433) male/57.6% (588) female, with a mean (SD) age of 54.1 (16.7) years were included in the study. Concordant pain provocation did not predict the magnitude of pain reduction (P = 0.9255) or the frequency of achieving > 50% pain relief (P = 0.7449) at short-term follow-up. Radiologic evidence of foraminal stenosis or nerve root impingement (P < 0.0001) and the lack of a medial-superior contrast flow pattern (P = 0.0199) were associated with a greater frequency of pain provocation during transforaminal ESI. LIMITATIONS: This study is primarily limited by possible selection bias given that patients who did not follow-up in the clinic could not be studied, and an incomplete follow-up rate (66%). Conclusions regarding subacute and long-term pain outcomes cannot be determined from this study as only short-term data were available. CONCLUSIONS: Provocation of concordant radicular pain does not predict pain relief at short-term follow-up after a transforaminal ESI. Foraminal stenosis, nerve root impingement, and lack of a medial-superior contrast flow pattern are associated with pain during the transforaminal ESI. Thus, clinicians should be aware of these radiologic and procedural risk factors for inciting pain during transforaminal ESI.

Programmatic design for teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents: a prospective multiyear study.

OBJECTIVE: The objective of this study was to determine the effectiveness of a 2-day course teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents. DESIGN: This is a 3-yr prospective study of a 2-day musculoskeletal course teaching the introductory skills and concepts of lumbar spinal procedures to the residents at a large academic physical medicine and rehabilitation program. The residents attending the course took multiple-choice pretests and posttests as well as participated in a procedural skills competency demonstration. RESULTS: Forty-two residents participated. The results were stratified according to the level of training and repetition of the material and revealed gains of medical knowledge at each level of residency training (P < 0.001). The postgraduate year 2 residents seemed to have the greatest overall improvement (P = 0.04). Half of the residents scored lower than 65% on the pretest, and these residents ultimately had the largest posttest gains. Forty (95.2%) residents achieved a grade of pass in the skills-based test. The residents felt that the course was valuable or extremely valuable. CONCLUSIONS: The comprehensive 2-day course teaching the skills and concepts of spinal interventions for physiatry residents enhances medical knowledge as an introduction to interventional spine care. Those who benefited the most were the residents who had the greatest deficit of medical knowledge on this topic before the course. This course curriculum does not replace fellowship training or closely monitored mentorship in the performance of spinal procedures.

Vitamin D status of patients admitted to a hospital rehabilitation unit: relationship to function and progress.

OBJECTIVE: The primary objective was to determine the association between vitamin D status, baseline function, and short-term inpatient rehabilitation progress. DESIGN: This was a prospective convenience sampling of 100 patients in a tertiary general hospital rehabilitation unit (RU). The cohort comprised men and women of mixed race with a variety of diagnoses (mean age 70 yrs). Patient histories and demographic information were obtained by patient interview and chart review. Serum 25-hydroxyvitamin D (25OHD) (nmol/L) was measured on or after the day of admission. The Functional Independence Measurement (FIM) instrument, a validated survey tool, was used to measure function at admission and discharge. RESULTS: Eleven percent of the patients were overtly vitamin D deficient, with serum 25OHD concentrations <20 nmol/L. Ninety-four percent of the patients had serum 25OHD concentrations below the recommended minimum optimal concentration of 80 nmol/L. Using the Spearman rank correlation test, low serum 25OHD was weakly but significantly associated with low total FIM scores: r = 0.25 (P < 0.012) and r = 0.23 (P < 0.021) for admission and discharge total FIM score, respectively. Patients with serum 25OHD concentrations greater than the median value of 41.3 nmol/L had significantly higher FIM efficiency scores (discharge total FIM score - admission total FIM score/length of stay [LOS]) than the subgroup of patients below the median (2.0 +/- 1.1 vs. 1.6 +/- 0.9, respectively; P < or = 0.026). Serum 25OHD was not significantly correlated with FIM efficiency or the unadjusted change in total FIM score (discharge total FIM score - admission total FIM score), but it was significantly correlated with LOS (the lower the serum 25OHD concentration, the longer the LOS, and vice versa; r = -0.235, P < 0.018). Thus, the difference in FIM efficiency between patients with serum 25OHD above and below the median was the result of the significant inverse correlation between serum 25OHD and LOS; as a group, patients with serum 25OHD above the median had a 19% shorter LOS than the group with serum 25OHD below the median value (11.4 +/- 4.9 vs. 14.1 +/- 5.6 days, respectively; P = 0.005). CONCLUSIONS: Most patients in a hospital RU had a suboptimal serum 25OHD concentration, reflecting what has previously been observed in hospitalized patients in general and also the population at large. Although no specific physical deficits or attributes could be directly attributed to low serum 25OHD, the baseline functional status of RU patients, LOS, and progress attributable to inpatient rehabilitation (FIM efficiency) were favorably affected by higher serum 25OHD concentrations.