Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study.

INTRODUCTION: Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran. METHODS: This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach. RESULTS: Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants. CONCLUSION: This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.

Efficacy of perineural hypertonic saline injection versus acupoints of foot in the management of diabetic neuropathy: a multicenter, double-blinded randomized controlled trial.

Aim: Painful diabetic polyneuropathy is one of the most common disabling problems worldwide. We aimed to determine if a perineural injection of hypertonic saline compared with foot acupoints decreased the neuropathic pain score in patients with diabetes. Patients & methods/materials: Patients were assigned to receive either perineural or acupoints injection of hypertonic saline 5% in their feet for three weekly sessions. Douleur Neuropathique 4 (DN4) questionnaire for neuropathic pain was assessed. Results: Both groups observed a significant reduction of the DN4 score throughout 8 weeks of follow-up. Conclusion: Both perineural and acupoints hypertonic saline injections of the foot could improve neuropathic pain in patients with diabetes.

We conducted a double blinded randomized clinical trial in 30 diabetic patients with painful neuropathic pain to determine if a perineural injection of hypertonic saline compared with foot acupoints decreased the neuropathic pain score in patients with diabetes. Subjects were assigned to receive either perineural (near Sural, Saphenous and Tibial nerves) or acupoints (ST41, ST44, GB40) injection of hypertonic saline 5% in one foot, keeping the other foot as control. Each patient underwent an injection at baseline followed by two injections, one week apart. The primary outcome was an assessment tool for neuropathic pain, called Douleur Neuropathique 4 questionnaire (DN4) score. It was measured before, during and 8 weeks after intervention. A significant reduction of DN4 score in perineural group and in the acupoint group throughout an 8 weeks follow-up was observed compared with the contralateral foot which was considered as the control group. The study revealed no significant differences between the perineural and the acupoints groups according to DN4 score. In conclusion, both perineural and acupoints of the foot hypertonic saline injections could improve neuropathic pain in diabetic patients with neither being superior to each other. The Clinical Trial Registration number was IRCT20170517034008N1.

Study of sympathetic skin response in patients with COVID-19 infection.

OBJECTIVES: Many articles hypothesized the potential role of autonomic nervous system in the pathogenesis and outcome of COVID-19 infection. Several studies reported both central and peripheral nervous system involvement in COVID-19 as well. Up to our knowledge, there is no study evaluating whether this virus could invade the autonomic nervous system affecting its function adversely. Sympathetic skin response (SSR) has long been used as a method of evaluating the autonomic nervous system. Regarding the importance of the autonomic nervous system in hemostasis and wide consequences of COVID-19 infection, we designed this study to evaluate the autonomic nervous system function in patients recovered from COVID-19 compared with normal population who are not yet infected by this virus by the means of SSR. METHODS: This case-control study included 70 patients surviving COVID-19 who met the inclusion and exclusion criteria that went under SSR. The data gathered were compared with those without the history of any symptoms attributable to COVID-19 during the pandemic. RESULTS: There was a correlation between COVID-19 infection and abnormal SSR (p value < 0.0001) with the most effect on the latency prolongation of the action potential recorded from the median nerve at palms (effect size: right: 3.90, left: 3.69). Moreover, the greater severity of the disease correlated with more abnormality of parameters recorded by SSR technique. CONCLUSIONS: Abnormal SSR parameters could be a good indicator of autonomic nervous system involvement in patients with COVID-19 infection. It might be a predictor of disease severity, clinical outcomes and prognosis as well.

A case of Guillain-Barre syndrome after the second dose of AstraZeneca COVID-19 vaccination.

Coronavirus disease 2019 (COVID-19) is a novel virus that primarily involves the respiratory system. Due to the COVID-19 pandemic, an extensive vaccination program is underway worldwide. Herein, we present a 68-year-old woman with paresthesia of both hands associated with gait instability, which started three to four days after receiving the second dose of Oxford/AstraZeneca vaccine against the COVID-19 infection. The acute inflammatory demyelinating polyradiculoneuropathy subtype of the Guillain-Barre syndrome, which is the most common subtype, was diagnosed. Regardless of the beneficial effects of the vaccines, this case report aimed to evaluate their severe complications, such as Guillain-Barre syndrome, to reduce their occurrence in the future.

Study of carpal tunnel syndrome in diabetic polyneuropathy with comparison of inching method and second lumbrical-interossei test.

Background: Since diabetic generalized neuropathy affects peripheral nerves, the diagnosis of carpal tunnel syndrome (CTS) with conventional electrodiagnostic techniques (EDX) [onset latency of median sensory nerve action potential (SNAP) or distal latency of median compound muscle action potential (CMAP)] is controversial. The aim of this study is to investigate the diagnostic values of two other techniques including inching method and second lumbrical-interossei test in patients with diabetic polyneuropathy (DPN) as well as signs or symptoms of CTS. Methods: Fifteen patients (30 hands) with definite diagnosis of generalized peripheral neuropathy secondary to diabetes who developed signs and symptoms of CTS were participated. For diagnosis of CTS, sensory and motor median distal latencies were considered by nerve conduction study. In the next step, inching method and second lumbrical-interossei test were performed for all hands. Finally, sensitivity and specificity of two tests were calculated. Results: Mean age of participants was 53.87 ± 11.53 years. The sensitivity and specificity of inching method in this study were 95.65% and 85.71%, respectively, and for the second lumbrical-interossei test, they were 73.91% and 71.42%, respectively. Conclusion: Inching method was more sensitive and specific than second lumbrical-interossei test in diagnosis of CTS among patients with diabetic peripheral neuropathy. Moreover, the sensitivity of inching method was greater than specificity.

Comparison of the Effectiveness of Ultrasound-Guided Prolotherapy in Supraspinatus Tendon with Ultrasound-Guided Corticosteroid Injection of Subacromial Subdeltoid Bursa in Rotator Cuff-Related Shoulder Pain: A Clinical Trial Study.

BACKGROUND: Shoulder pain is the third most common type of musculoskeletal disorder and rotator cuff (RC) tendinopathy is the most frequent diagnosis. Ultrasound is the most preferable guidance tool for diagnostic and interventional purposes. The aim of this study is to compare the effectiveness of the prolotherapy injection with corticosteroid injection in patients with RC dysfunction. MATERIALS AND METHODS: Thirty to sixty-five-year-old patients with chronic RC disease were divided into two groups. Ultrasound-guided dextrose prolotherapy of supraspinatus tendon was done for one group and ultrasound-guided corticosteroid injection in the subacromial bursa was done for the other groups. Visual analog scale (VAS) and Shoulder Pain and Disability Index (SPADI) were evaluated for both groups at baseline, 3 and 12 weeks after injections. RESULTS: Thirty-three patients were included in the result. Both the groups showed significant improvement in VAS and SPADI scores in 3 and 12 weeks after injections compared with preinjection times with no difference between two groups neither in 3 weeks nor in 12 weeks after injections. CONCLUSION: Both ultrasound-guided dextrose prolotherapy and CS injections are effective in the management of RC-related shoulder pain in both short-term and long-term with neither being superior to the other. Therefore, prolotherapy may be a safe alternative therapy instead of corticosteroid injection due to lack of its side effects.