Anatomical study and proposed EMG technique for the cervical paraspinal muscles.

Paraspinal electromyography has proven to be the most sensitive component of the electrodiagnostic examination for lumbar spinal disorders. However, no standardized, anatomically validated technique has been proposed for the cervical region. This study reviewed the published textbooks on cervical paraspinal anatomy to develop a standardized electromyography technique and scoring system. A library search found 32 anatomy texts published between 2000 and 2021. Of these 11 were unique and appropriate. Most texts described the basic muscle anatomy similarly, but only one cited original research. When the spinous process is defined as the origin, the multifidus and deeper rotatores appear innervated by the posterior primary rami of single cervical roots. However, texts differ in the number of pennae, between two and five, traveling to transverse process regions below. These are crowded into a small area between the spinous processes and transverse processes. Based on this understanding, a proposed cervical paraspinal mapping technique involves skin insertions from 1 to 2 cm lateral to the C5, C7, and T2 spinous processes. The needle samples transversely and deep toward midline, contacts bone, then is withdrawn and redirected to sample medial and caudally to midline to bone, creating two scores of 0-4 at three levels, theoretically resulting in scores of 0-24. This technique must be validated by clinical research to determine the range of normal, reproducibility, and the spectrum of findings in various disorders.

A review of electromyography techniques of the cervical paraspinal muscles.

Electrodiagnosis for cervical radiculopathy often involves exploration of the cervical paraspinal muscles. Accurate and reproducible results require a technique with specific anatomic localization, direction of insertion, extent of insertion, scoring system for insertion, and criteria for determining abnormality. We sought to understand if a published technique met these criteria. A Medline search found 39 articles with original research and 10 review articles involving the cervical paraspinals. A library search found 19 textbooks since 2000, but 9 were not available. Only two studies were specific to the question. Neither had reproducible techniques and they contradicted each other. Studies in which the paraspinals were used for comparison or inclusion did not provide any specific technique. The review articles and textbooks typically met none of our criteria and the few that discussed technique at all provided no reproducible methods. Despite 80 years of electrodiagnostic testing, there is no useful, reproducible technique for exploring the cervical paraspinal muscles. Yet such a paraspinal mapping technique has proven invaluable in the lumbar region. For cervical electromyography to be of value, the next step is to understand the anatomy and propose a reproducible technique. Subsequent research will determine whether the neck muscles are helpful in the diagnosis of cervical radiculopathy. The absence of a valid reproducible cervical paraspinal technique impedes clinical and scientific understanding of cervical radiculopathy.

Building PRM in sub-Saharan Africa.

It is estimated that about 50% of people in low- and middle- income countries who require rehabilitation do not get it. Multidisciplinary rehabilitation services led by Physical and Rehabilitation Medicine (PRM) physicians have been shown to improve functioning, independence and the quality of life of persons with reduced functioning or disability. However, there is a dearth of PRM physicians in low to middle income countries (LMICs), particularly in sub-Saharan Africa. One potential solution to this lack of specialists is the establishment of PRM training programs, which are currently lacking. The International Rehabilitation Forum (IRF) developed and implemented a fellowship program to train physicians in rehabilitation medicine and has been successful in Ghana, Ethiopia and Cameroon, all LMICs in sub-Saharan Africa. However, ongoing challenges include inadequate PRM trainers, availability of logistics and services for hands on experience, and funding. The fellowship program has a promising future and an ultimate goal of having locally trained fellows leading the program and expanding it to other LMICs. There has however been no publication of the process followed to achieve this or of a similar process undertaken anywhere in Africa. The process followed in this publication highlights the journey from engaging stakeholders to the admission of new and current fellows in training.

Consensus on a standardised treatment pathway algorithm for lumbar spinal stenosis: an international Delphi study.

BACKGROUND: Lumbar spinal stenosis (LSS) is a common degenerative spinal condition in older adults associated with disability, diminished quality of life, and substantial healthcare costs. Individual symptoms and needs vary. With sparse and sometimes inconsistent evidence to guide clinical decision-making, variable clinical care may lead to unsatisfactory patient outcomes and inefficient use of healthcare resources. METHODS: A three-phase modified Delphi study comprising four consensus rounds was conducted on behalf of the International Taskforce for the Diagnosis and Management of LSS to develop a treatment algorithm based on multi-professional international expert consensus. Participants with expertise in the assessment and management of people with LSS were invited using an international distribution process used for two previous Delphi studies led by the Taskforce. Separate treatment pathways for patients with different symptom types and severity were developed and incorporated into a proposed treatment algorithm through consensus rounds 1 to 3. Agreement with the proposed algorithm was evaluated in the final consensus round. RESULTS: The final algorithm combines stratified and stepped approaches. When indicated, immediate investigation and surgery is advocated. Otherwise, a stepped approach is suggested when self-directed care is unsatisfactory. This starts with tailored rehabilitation, then more complex multidisciplinary care, investigations and surgery options if needed. Treatment options in each step depend on clinical phenotype and symptom severity. Treatment response guides pathway entrance and exit points. Of 397 study participants, 86% rated their agreement ≥ 4 for the proposed algorithm on a 0-6 scale, of which 22% completely agreed. Only 7% disagreed. Over 70% of participants felt that the algorithm would be useful for clinicians in public healthcare (both primary care and specialist settings) and in private healthcare settings, and that a simplified version would help patients in shared decision-making. CONCLUSIONS: International and multi-professional agreement was achieved for a proposed LSS treatment algorithm developed through expert consensus. The algorithm advocates different pathway options depending on clinical indications. It is not intended as a treatment protocol and will require evaluation against current care for clinical and cost-effectiveness. It may, however, serve as a clinical guide until evidence is sufficient to inform a fully stratified care model.

Cancer rehabilitation as an essential component of quality care and survivorship from an international perspective.

Background: There has recently been an emphasis on improving cancer care globally, including access to lifesaving treatment and earlier identification of disease. This will lead to more survivors stricken by impairments related to the early and late effects of cancer treatment. An unintended consequence of the noble plan to improve oncology care worldwide is demand on health care systems that may be unable to accommodate increased patient care needs for myriad reasons. As a result, those with disabilities may suffer.Methods: Literature search and input from experts in the field were used to evaluate the growing need for cancer rehabilitation and survivorship care to reduce morbidity associated with cancer treatment.Results: Many governmental and non-governmental organizations have started initiatives to improve cancer care across the continuum, and reduce the symptom burden of those living with cancer. While the start is promising, many barriers must be overcome to ensure high-quality care that would reduce cost and improve patient access, including a lack of trained rehabilitation specialists, poor coordination of efforts, and funding restrictions. Furthermore, global efforts to improve rehabilitation care often do not emphasize cancer rehabilitation, potentially leaving a gap and increasing physical and economic costs of disability. Finally, low-resource countries face unique challenges in improving cancer rehabilitation care.Conclusion: Cancer rehabilitation and survivorship care are needed to improve health care quality, as there is an expected influx of cancer patients with new global efforts to improve oncology care. To accomplish this, rehabilitation initiatives must emphasize cancer rehabilitation as a component of any program, and oncology endeavors should include a plan for the rehabilitation of cancer survivors to reduce morbidity and health care cost.Implications for RehabilitationCancer rehabilitation has the potential to reduce morbidity and health care costs associated with cancer and disability worldwideAdvocacy from international organizations regarding cancer rehabilitation is increasing, but has been disjointed and incompleteLow-resource countries in particular face several barriers to providing cancer rehabilitation and survivorship care.

Rehabilitation in Africa.

In Africa, rehabilitation services are insufficient and marred with inadequate political commitments and collaborations of stakeholders. Infrastructures and expertise for rehabilitation are scarce and poorly coordinated. Community-based rehabilitation programs are fragmented and fractured and lack working partnership with rehabilitation services in health care systems. Locally responsive policy frameworks, service delivery models, and health governance practices are prerequisites for meeting rehabilitation needs of the ever-increasing number of persons with chronic disabling conditions. Concerted global efforts are required for equitable and accessible coordinated continuum of rehabilitation care at various levels of health services and the community in most Sub-Saharan African countries.

Intimate Partner Violence and Women's Health-seeking Behaviors in Northwestern Botswana.

Despite evidence suggesting a strong association between women's experience of violence and their health-seeking behaviors, limited research has been conducted to date that explores factors associated with these behaviors in Botswana. A prospective, cross-sectional study involving semi-structured interviews with 479 women took place in Maun, Botswana, in 2012. Twenty-five percent of those interviewed reported not having visited a medical clinic at least once despite wishing to do so. Sequential binary-logistic regressions identified three factors associated with women's health services utilization: travel time, frequency of clinic visits, and experience of recent sexual intimate partner violence (IPV). Women who had experienced recent sexual IPV had over two and a half times the odds of having foregone medical care compared with women with no recent sexual IPV experience. Interventions that identify and encourage victims of sexual violence to seek timely screening and treatment may reduce overall disease burden in this population.

Clinical predictors of the medical interventions provided to patients with low back pain in the emergency department.

BACKGROUND: Low back pain is a common complaint in emergency departments (ED), where deviations from standard of care have been noted. OBJECTIVE: To relate the ordering of advanced imaging and opioid prescriptions with the presentation of low back pain in ED. METHODS: Six hundred adults with low back pain from three centers were prospectively analyzed for history, examination, diagnosis, and the ordering of tests and treatments. RESULTS: Of 559 cases the onset of pain was less than one week in 79.2%; however, most had prior low back pain, 63.5% having warning signs of a potential serious condition, and 83.9% had psychosocial risk factors. Computer tomography (CT) or magnetic resonance imaging (MRI) were ordered in 16.6%, opioids were prescribed in 52.6%, and hospital admission in 4.5%. A one-year follow-up of 158 patients found 40.8% received subsequent spine care and 5.1% had a medically serious condition. Caucasian race, age 50 years or older, warning signs, and radicular findings were associated with advanced imaging. Severe pain and psychosocial factors were associated with opioid prescribing. CONCLUSIONS: Most patients present to the ED with acute exacerbations of chronic low back pain. Risk factors for a serious condition are common, but rarely do they develop. Racial disparities and psychosocial factors had concerning relationships with clinical decision-making.

Distress prior to undergoing hematopoietic stem cell transplantation: demographic and symptom correlations and establishing a baseline.

BACKGROUND: Distress can arise from physical and/or psychosocial impairments and has been documented in patients after hematopoietic stem cell transplantation in the outpatient setting. It has not been evaluated in inpatients admitted to undergo the transplant, nor has potential correlations with length of hospital stay, physical function, and pain after receiving the transplant. OBJECTIVES: To measure distress in patients admitted to the hospital to undergo hematopoietic stem cell transplantation, and to evaluate potential correlations with length of hospital stay, physical function, pain, and depression/anxiety. METHODS: Eighty patients were given a questionnaire to report levels of distress and physical and psychosocial functioning. Hierarchical multiple regression analysis was used to test the relationship of demographic and transplant factors with length of stay (LOS), distress, presence of pain, and depression/anxiety. RESULTS: Patients reported pretransplant distress with an average score of 2.2 out of 10, and 16 out of 80 patients reported clinically relevant distress. Pain was reported by 42.5% of patients, and 28.8% reported depression/anxiety. Physical functioning was generally high. Distress was correlated with depression/anxiety (P-value <0.01) and pain (0.04) but not with LOS, physical function, patient age, or transplant type. CONCLUSION: LOS after receiving stem cell transplant was not related to pretransplant distress. Distress exists pretransplant but is generally low. Pain and the presence of depression/anxiety may be risk factors for distress. Measuring distress prior to transplant gives a baseline from which to measure changes, potentially leading to earlier intervention.

ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.

STUDY DESIGN: Delphi. OBJECTIVE: The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. METHODS: Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. RESULTS: A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were "leg or buttock pain while walking," "flex forward to relieve symptoms," "feel relief when using a shopping cart or bicycle," "motor or sensory disturbance while walking," "normal and symmetric foot pulses," "lower extremity weakness," and "low back pain." Significant change in certainty ceased after six questions at 80% (P < .05). CONCLUSION: This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of "seven history items" that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. LEVEL OF EVIDENCE: 2.

Spinal Stenosis: Factors That Influence Patients' Decision to Undergo Surgery.

STUDY DESIGN: Prospective noninterventional observation. OBJECTIVE: To examine factors that influence a patient's real decision to accept the offer of surgery for lumbar spinal stenosis in a relatively controlled situation. SUMMARY OF BACKGROUND DATA: A patient's decision to undergo spine surgery might be influenced by factors other than pathology. However, there is limited research exploring the decision. METHODS: A study performed for other purposes recruited persons aged 55-90 years with medical record evidence of an offer of surgery for spinal stenosis by a university faculty surgeon. Inclusion criteria included neurogenic claudication, subjectively positive imaging, and difficulty walking 200 yards. Potential subjects with additional disabling conditions (eg, lower limb amputation), conditions that might mimic stenosis (eg, polyneuropathy), or some contraindications to invasive treatment (eg, anticoagulation) were excluded. Subjects filled out questionnaires on function, quality of life, pain, and health, and were examined by a spine surgeon masked to diagnostic category (Other recruits had back pain or no symptoms). Telephone follow-up 6-12 months later determined whether surgery was done. RESULTS: Of 39 qualifying subjects, 20 followed through with surgery. A binary logistic regression revealed that significant factors that influence patient decision making included SF-36 measures of "Comparative Health" and "Role Limit Emotional" as well as the subject's overall perception of their quality of life. The combination of all 3 factors yielded a predictive model (P=0.031). Individually, however, only "Comparative Health" was significant and able to predict a decision to proceed with surgery (P=0.036). CONCLUSIONS: In this population with significant disability, uncomplicated medical history, and a relatively clear diagnosis, the decision to accept surgical intervention was influenced by issues of perceived overall health and quality of life. Interventions to change real or perceived overall health may impact patient acceptance of surgery.

Practical assessment in patients suffering from musculoskeletal disorders.

Short review of exemplary clinical assessment methods to describe clinical evidence-based assessment for patients suffering from symptoms of musculoskeletal pain.History and physical examination are the primary evidence-based assessment instruments for pain patients. Pain scales and questionnaire might allow assessment of different aspects of pain in order to perform an individualized therapy for pain patients.

Controlling the Midfield: Treating Patients With Chronic Pain Using Alternative Payment Models.

The entire American health care system is turning upside down, except for the parts that aren't--yet. For physiatrists who manage pain problems, the future is complex. The usual challenge of treating these devastating and costly problems that cannot be measured physiologically is compounded by the requirement to do so in a health care system that doesn't know what it wants to be yet. Payment, regulation, and the very structure of practice are changing at a pace that is halting and unpredictable. Nonetheless, knowledge about some structures is necessary, and some themes almost certainly emerge. I propose that the role of the pain physiatrist is best understood through a soccer analogy. Whereas the casual spectator of the past might note the goals scored by surgical colleagues and shots missed by primary care partners, sophisticated health care systems of the future will learn that the pain game is won by creating a strong physiatry midfield. Physiatrists can reach to the backfield to help primary care with tough cases, send accurate referrals to surgeons, and reorganize the team when chronic pain complicates the situation. Current and emerging payment structures include insurance from government, employers, or individuals. Although the rules may change, certain trends appear to occur: Individuals will be making more choices, deductibles will increase, narrow groups of practitioners will work together, pricing will become important, and the burden on primary care colleagues will increase. Implications of each of these trends on pain medicine and specific strategy examples are addressed. A general concept emerges that, although procedure- and activity-based practice is still important, pain physiatrists can best prepare for the future by leading programs that create value for their health care system.