Deconstructing chronic low back pain in the older adult--Step by step evidence and expert-based recommendations for evaluation and treatment part III: Fibromyalgia syndrome.

OBJECTIVE: To present the third in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributors to pain and disability in older adults with CLBP. This article focuses on fibromyalgia syndrome (FMS). METHODS: A modified Delphi approach was used to create the evaluation and treatment algorithm, the table discussing the rationale behind each of the algorithm components, and the stepped-care drug recommendations. The team involved in the creation of these materials consisted of a principal investigator, a 5-member content expert panel, and a 9-member primary care panel. The evaluation and treatment recommendations were based on availability of medications and other resources within the Veterans Health Administration (VHA) facilities. However, non-VHA panelists were also involved in the development of these materials, which can be applied to both VA and civilian settings. The illustrative clinical case was taken from the clinical practice of the principal investigator. RESULTS: Following expert consultations and a review of the literature, we developed an evaluation and treatment algorithm with supporting materials to aid in the care of older adults with CLBP who have concomitant FMS. A case is presented that demonstrates the complexity of pain evaluation and management in older patients with CLBP and concomitant FMS. CONCLUSIONS: Recognition of FMS as a common contributor to CLBP in older adults and initiating treatment targeting both FMS and CLBP may lead to improved outcomes in pain and disability.

Spine fractures in ankylosing spondylitis: a case report and review of imaging as well as predisposing factors to falls and fractures.

BACKGROUND: Ankylosing spondylitis (AS), an inflammatory arthritis that affects the axial skeleton, predisposes patients with severe disease to falls and spinal fractures. Advanced imaging has improved the process of fracture detection. In spite of increased knowledge about early diagnosis and management of AS, little attention is being paid to the environmental hazards that pose a risk for patient outcome. OBJECTIVES: To identify risk factors for falls and fractures and evaluate imaging modalities in the detection of fractures in AS patients. METHODS: A case report and review of the literature using PubMed for English articles from 2000 to 2013 regarding AS patients׳ risk factors for falls and fractures and imaging modalities used to diagnose fracture in this population. RESULTS: Potential impairments in balance and coordination in the AS population include vestibular dysfunction, thoracolumbar kyphosis, and deficits in proprioception. A common and significant environmental risk factor for falls includes the use of a tub-shower arrangement. Furthermore, osteoporosis is a well-known complication of AS, which can predispose to a fracture. Lastly, there are no comprehensive studies that have evaluated the ability of advanced imaging modalities to identify an acute spine fracture in this patient population. CONCLUSIONS: AS patients with advanced disease are at an increased risk of falls and fractures due to many factors including but not limited to a rigid spine and difficulty with peripheral vision. A tub-shower arrangement commonly found in homes and hotel rooms is a major hazard. A consistent approach to diagnosis of fractures involving advanced imaging recommendations should be considered.

A combined scoring method to assess behavioral recovery after mouse spinal cord injury.

Although the rat has been the predominant rodent used to investigate the pathophysiology and treatment of experimental spinal cord injury (SCI), the increasing availability of transgenic animals has led to greater use of mouse models. However, behavioral assessment after SCI in mice has been less extensively investigated than in rats and few studies have critically examined the correlation between behavioral tests and injury severity or tissue damage. The present study characterized hindlimb functional performance in C57Bl/6 mice after contusion SCI at T9 using the weight drop method. A number of behavioral tests were examined with regard to variability, inter-rater reliability, and correlation to injury severity and white matter sparing. Mice were subjected to sham, mild-moderate or moderate-severe SCI and evaluated at day 1 and weekly up to 42 days using the Basso mouse scale (BMS), ladder climb, grid walk, inclined plane, plantar test and tail flick tests. The ladder climb and grid walk tests proved sub-optimal for use in mice, but modifications enhanced their predictive value with regard to injury severity. The inclined plane, plantar test and tail flick test showed far too much variability to have meaningful predictive value. The BMS score proved reliable, as previously reported, but a combined score (BLG) using BMS, Ladder climb (modified), and Grip walk (modified grid walk) provided better separation across injury levels and less variability than the individual tests. These data provide support for use of a combined scoring method to follow motor recovery in mice after contusion SCI.