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1.  Kinesiophobia and Fear Avoidance Beliefs in Overweight Older Adults with Chronic Low Back Pain, Relationship to Walking Endurance: Part II 
This study determined whether kinesiophobia levels were different among older adults with chronic low back pain (LBP) and varying body mass index (BMI) and whether kinesiophobia predicted perceived disability or walking endurance.
This study was a secondary analysis from a larger interventional study. Obese, older adults with LBP (N=55; 60-85 years) were participants in this study. Data were stratified based on BMI: overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2) and severely obese (35 kg/m2). Participants completed a battery of surveys (modified Tampa Scale of Kinesiophobia [TSK-11], Fear Avoidance Beliefs [FAB], Pain Catastrophizing scale [PCS], and perceived disability measures of the Oswestry Disability Index [ODI], Roland Morris Disability Questionnaire [RMDQ]). Walking endurance time was captured using a symptom limited graded walking treadmill test. Peak LBP ratings were captured during the walk test.
Walking endurance times did not differ by BMI group, but peak LBP ratings were higher in the moderate and severely obese groups compared to the overweight group (3.0 and 3.1 points vs. 2.1; p<0.05). There were no difference in the kinesiophobia scores (TSK-11, PCS, FAB work and activity subscores) or the perceived disability scores (ODI, RMD). However, adjusted regression analyses revealed that TSK-11 scores contributed 10-21% of the variance of the models pain with walking and perceived disability due to back pain. Kinesiophobia was not a significant contributor to the variance of the regression modeling for walking endurance.
In the obese older population with LBP, the TSK-11 might be a quick and simple measure to identify patients at risk for poor self-perception of functional ability The TSK and ODI may be quick useful measures to assess initial perceptions before rehabilitation. Kinesiophobia may be a good therapeutic target to address to help affected obese older adults fully engage in therapies for LBP.
PMCID: PMC3647684  PMID: 23478452
Low Back Pain; Obesity; Kinesiophobia; Multifidus
2.  Functional Pain Severity and Mobility in Overweight Older Men and Women with Chronic Low Back Pain: Part I 
This study determined whether mobility and functional pain were different among older men and women with chronic low back pain (LBP) and varying body mass index (BMI) levels.
This was a comparative, descriptive study of obese, older adults with LBP (N=55; 60-85 years). Participants were stratified based on BMI: overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2) and severely obese (35 kg/m2). Participants completed a functional test battery (walking endurance, chair rise, stair climb, 7-day activity monitoring, gait parameters) and pain ratings with activity (‘functional pain’).
Functional pain scores during walking and stair climb were highest in the severely obese group compared with the overweight group (p<0.05), but functional test scores were not found to be significantly different by BMI. Gait base of support was 36% greater and single/double support times were 3.1-6.1% greater in the severely obese group compared to the overweight group (p<0.05). Women had slower chair rise and stair climb times, and had slower walking velocity than men. Daily step numbers were lowest in the severely obese group compared with the obese and overweight groups (2971 vs 3511 and 4421 steps/day; p<0.05), but were not different by gender. Normalized lumbar extensor, abdominal curl and leg press strength values were lowest in the severely obese group, and women had 18-34% lower strength values than men for all three exercises (p<0.05). Lumbar strength was associated with stair climb, chair rise and walking endurance times. BMI was an independent predictor of walking endurance time, but not steps taken per day.
In this study, obese persons reported higher functional pain values during walking and stair climb compared to overweight participants, and had lower lumbar strength. Rehabilitation strategies that include lumbar extensor strengthening may help improve functional mobility and walking duration, both of which can help with weight management in the obese, older adult with chronic LBP.
PMCID: PMC3676903  PMID: 23478453
Low Back Pain; Obesity; Walking; Physical Function; Body Mass Index
3.  Epidural Lysis of Adhesions 
The Korean Journal of Pain  2013;27(1):3-15.
As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that percutaneous LOA is more effective than conventional ESI for both failed back surgery syndrome, spinal stenosis, and lumbar radiculopathy. For cervical HNP, cervical stenosis and mechanical pain not associated with nerve root involvement, the evidence is anecdotal. The benefits of LOA stem from a combination of factors to include the high volumes administered and the use of hypertonic saline. Hyaluronidase has been shown in most, but not all studies to improve treatment outcomes. Although infrequent, complications are more likely to occur after epidural LOA than after conventional epidural steroid injections.
PMCID: PMC3903797  PMID: 24478895
epidural adhesiolysis; epidural lysis of adhesions; epidural neuroplasty; epiduroscopy; failed back surgery syndrome
4.  Sex, Gender, and Pain: An Overview of a Complex Field 
Anesthesia and analgesia  2008;107(1):309-317.
Traditionally, biomedical research in the field of pain has been conducted with male animals and subjects. Over the past 20–30 yr, it has been increasingly recognized that this narrow approach has missed an important variable: sex. An ever-increasing number of studies have established sex differences in response to pain and analgesics. These studies have demonstrated that the differences between the sexes appear to have a biological and psychological basis. We will provide brief review of the epidemiology, rodent, and human experimental findings. The controversies and widespread disagreement in the literature highlight the need for a progressive approach to the questions involving collaborative efforts between those trained in the basic and clinical biomedical sciences and those in the epidemiological and social sciences. In order for patients suffering from acute and/or chronic pain to benefit from this work, the approach has to involve the use or development of clinically relevant models of nociception or pain to answer the basic, but complex, question. The present state of the literature allows no translation of the work to our clinical decision-making.
PMCID: PMC2715547  PMID: 18635502
6.  Patient perception of pain care in hospitals in the United States 
Journal of pain research  2009;2:157-164.
Study objective
Assessment of patients’ perception of pain control in hospitals in the United States.
Limited data are available regarding the quality of pain care in the hospitalized patient. This is particularly valid for data that allow for comparison of pain outcomes from one hospital to another. Such data are critical for numerous reasons, including allowing patients and policy-makers to make data-driven decisions, and to guide hospitals in their efforts to improve pain care. The Hospital Quality Alliance was recently created by federal policy makers and private organizations in conjunction with the Centers for Medicare and Medicare Services to conduct patient surveys to evaluate their experience including pain control during their hospitalization.
In March 2008, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was released for review for health care providers and researchers. This survey includes a battery of questions for patients upon discharge from the hospital including pain-related questions and patient satisfaction that provide valuable data regarding pain care nationwide. This study will review the results from the pain questions from this available data set and evaluate the performance of these hospitals in pain care in relationship to patient satisfaction. Furthermore, this analysis will be providing valuable information on how hospital size, geographic location and practice setting may play a role in pain care in US hospitals.
The data indicates that 63% of patients gave a high rating of global satisfaction for their care, and that an additional 26% of patients felt that they had a moderate level of global satisfaction with the global quality of their care. When correlated to satisfaction with pain control, the relationship with global satisfaction and “always” receiving good pain control was highly correlated (r >0.84). In respect to the other HCAHPS components, we found that the patient and health care staff relationship with the patient is also highly correlated with pain relief (r >0.85). The patients’ reported level of pain relief was significantly different based upon hospital ownership, with government owned hospitals receiving the highest pain relief, followed by nonprofit hospitals, and lastly proprietary hospitals. Hospital care acuity also had an impact on the patient’s perception of their pain care; patients cared for in acute care hospitals had lower levels of satisfaction than critical access hospitals.
The results of this study are a representation of the experiences of patients in US hospitals with regard to pain care specifically and the need for improved methods of treating and evaluating pain care. This study provides the evidence needed for hospitals to make pain care a priority in to achieve patient satisfaction throughout the duration of their hospitalization. Furthermore, future research should be developed to make strategies for institutions and policy-makers to improve and optimize patient satisfaction with pain care.
PMCID: PMC3004628  PMID: 21197302
pain care; HCAHPS; hospitals
7.  Randomized Placebo-Controlled Study Evaluating Lateral Branch Radiofrequency Denervation for Sacroiliac Joint Pain 
Anesthesiology  2008;109(2):279-288.
Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain.
A randomized, placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-5 primary dorsal rami and S1-3 lateral branch radiofrequency denervation using cooling-probe technology following a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who failed to respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology.
One, 3 and 6-months post-procedure, 11 (79%), 9 (64%) and 8 (57%) of radiofrequency treated patients experienced ≥ 50% pain relief and significant functional improvement. In contrast, only 2 (14%) patients in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3-months post-procedure. In the crossover group (n=11), 7 (64%), 6 (55%) and 4 (36%) patients experienced improvement 1, 3 and 6-months post-procedure. One year after treatment, only 2 (14%) patients in the treatment group continued to demonstrate persistent pain relief.
These results provide preliminary evidence that L4 and L5 primary dorsal rami and S1-3 lateral branch radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain. Larger studies are needed to confirm our results, and determine the optimal candidates and treatment parameters for this poorly understood disorder.
PMCID: PMC2666931  PMID: 18648237
8.  A Prospective, Observational Study of the Relationship Between Body Mass Index and Depth of the Epidural Space During Lumbar Transforaminal Epidural Steroid Injection 
Background and Objectives
Previous studies have concluded that transforaminal epidural steroid injections (ESIs) are more effective than interlaminar injections in the treatment of radiculopathies due to lumbar intervertebral disk herniation. There are no published studies examining the depth of epidural space using a transforaminal approach. We investigated the relationship between body mass index (BMI) and the depth of the epidural space during lumbar transforaminal ESIs.
Eighty-six consecutive patients undergoing lumbar transforaminal ESI at the L3-L4, L4-L5, and L5-S1 levels were studied. Using standard protocol, the foraminal epidural space was attained using fluoroscopic guidance. The measured distance from needle tip to skin was recorded (depth to foraminal epidural space). The differences in the needle depth and BMI were analyzed using regression analysis.
Needle depth was positively associated with BMI (regression coefficient [RC], 1.13; P < 0.001). The median depths (in centimeters) to the epidural space were 6.3, 7.5, 8.4, 10.0, 10.4, and 12.2 for underweight, normal, preobese, obese I, obese II, and obese III classifications, respectively. Sex (RC, 1.3; P = 0.02) and race (RC, 0.8; P = 0.04) were also significantly associated with needle depth; however, neither factor remained significant when BMI was accounted as a covariate in the regression model. Age, intervertebral level treated, and oblique angle had no predictive value on foraminal depth (P > 0.2).
There is a positive association between BMI and transforaminal epidural depth, but not with age, sex, race, oblique angle, or intervertebral level.
PMCID: PMC2715548  PMID: 19282707

Results 1-8 (8)