Publications by authors named "Ryan Mattie"

39 Publications

Vertebral Augmentation of Cancer-Related Spinal Compression Fractures: A Systematic Review and Meta-Analysis.

Spine (Phila Pa 1976) 2021 May 6. Epub 2021 May 6.

Department of Interventional Pain Management, Providence Cedars-Sinai Tarzana Medical Center, Los Angeles, CA, USA Department of Interventional Pain Management, Providence St. Joseph Health Southern California, Mission Hills, CA, USA University of California San Diego School of Medicine, San Diego, CA, USA Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT, USA. Spine Fracture Institute, Edmond, OK, USA Director of Neuro-Spine Surgery, Providence Cedars Sinai Tarzana Medical Center, Los Angeles, CA, USA Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland.

Study Design: Systematic review and meta-analysis.

Objective: To compare the magnitude and duration of pain relief with vertebral augmentation to any other therapy for the treatment of cancer-related vertebral compression fractures through meta-analysis of randomized controlled trials.

Summary Of Background Data: Derived from search on PubMed, EMBASE, CINAHL, Scopus, Central, Scopus and Web of Science databases in May 2020. Studies selected were limited to randomized controlled trials comparing vertebral augmentation, either Balloon Kyphoplasty (BKP) or Percutaneous Vertebroplasty (PVP) with or without additional therapy to any other intervention or placebo/sham.

Methods: The methodological quality of each included study was assessed according to the Cochrane Collaboration's domain-based framework. Random-effects model. Heterogeneity assessed using the Q test and I2 statistic.

Results: Of 180 records identified, 7 were considered relevant, and included 476 participants. The risk of bias was considered "Low" in all studies. In five of the studies, vertebral augmentation alone (either PVP or BKP) comprised one group, while comparative treatments included non-surgical management, Kiva implantation, PVP and radiofrequency therapy, PVP and chemotherapy, PVP and intra-somatic injection of steroid, and PVP with 125I seeds. Two studies compared PVP with an additional therapy against the standard of care. With regard to changes in pain severity, the effect sizes varied from 0.0 (95% -1.7 to 1.7) to -5.1 (95% -5.3 to -4.9). Most studies demonstrated a positive and statistically significant effect associated with PVP. Four of the 7 studies demonstrated a clinically significant effect as well. Other than cement leakage, with an event rate of 0.24 (95% CI 0.11 to 0.44) or 24% (95% CI 11% to 44%), there were no major adverse events consistently observed across multiple studies.

Conclusions: The included randomized controlled trials demonstrated an overall positive and statistically significant effect of vertebral augmentation surgeries, such as vertebroplasty and kyphoplasty, for the treatment of cancer-related vertebral compression fractures, especially when compared to non-surgical management, radiofrequency ablation or chemotherapy alone.Level of Evidence: 1.
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http://dx.doi.org/10.1097/BRS.0000000000004093DOI Listing
May 2021

Corticosteroid Injections and COVID-19 Infection Risk.

Pain Med 2020 08;21(8):1703-1706

Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA.

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http://dx.doi.org/10.1093/pm/pnaa199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454880PMC
August 2020

Anticoagulants for Lumbar Epidural Steroid Injections.

Pain Med 2020 06;21(6):1294-1295

Rehabilitation and Regenerative Medicine, Columbia University Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1093/pm/pnaa087DOI Listing
June 2020

Are there gender-related differences in the psychometric properties of the Oswestry Disability Index?

Eur J Phys Rehabil Med 2020 Oct 26;56(5):594-599. Epub 2020 May 26.

Department of Physical and Rehabilitation Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.

Background: Despite the wide body of research on the properties of the Oswestry Disability Index (ODI), only a few studies have investigated whether ODI scores can be interpreted similarly in both genders. A few previous studies suggested that the ODI may behave differently in different populations, e.g. in different age groups.

Aim: The objective was to investigate gender-related differences in the psychometric properties of the ODI amongst patients with chronic low back pain.

Design: Observational cross-sectional cohort study.

Setting: University outpatient Physical and Rehabilitation Medicine clinic.

Population: Consecutive patients seen in an outpatient Physical and Rehabilitation Medicine clinic at a university hospital between April 2014 and February 2017.

Methods: Internal consistency was evaluated using Cronbach's alpha. Factor structure was investigated using exploratory factor analysis. Gender-related differences in psychometric properties of ODI items were assessed using item response theory analysis.

Results: The study included 912 patients, 579 women (63%), with an average age of 45.8 (SD 14.2) years old. The Cronbach's alpha for both genders was good at 0.88. The discrimination abilities of all 10 ODI items were mostly high to perfect for both men and women with only small fluctuations. The item information function curves were similar for most of the items. Exploratory factor analysis resulted in a unidimensional one-factor structure for both genders.

Conclusions: The ODI appears to be a similarly unidimensional and internally consistent questionnaire in both genders without any substantial variability in the items' difficulty and discrimination.

Clinical Rehabilitation Impact: The ODI produces psychometrically similar results in both genders. Small and clinically hardly significant gender-related differences in the properties of ODI can be neglected.
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http://dx.doi.org/10.23736/S1973-9087.20.06157-2DOI Listing
October 2020

Frequency of Epidural Steroid Injections.

Pain Med 2020 05;21(5):1078-1079

Columbia University Medical Center, Rehabilitation and Regenerative Medicine, New York, New York, USA.

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http://dx.doi.org/10.1093/pm/pnaa053DOI Listing
May 2020

The Reliability of a Grading System for Digital Subtraction Imaging Quality During Cervical Transforaminal Epidural Steroid Injection.

Pain Med 2020 11;21(11):3126-3132

Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA.

Objective: Digital subtraction imaging (DSI) decreases the risk of intravascular injection during cervical transforaminal epidural steroid injection (CTFESI); however, sequence acquisition and interpretation are operator-dependent skills. This study tests the reliability of a grading system to determine adequate DSI during CTFESI.

Setting: Academic tertiary medical center.

Methods: A grading scheme for adequate DSI quality during CTFESI was created by the study authors based on patient positioning, mask image, and volume of contrast injected. The inter-rater and intrarater reliability values of this grading scheme were tested using 50 DSI images evaluated by three raters during two distinct sessions separated by four weeks. Based on a power analysis, a sample of 50 scans was sufficient to detect significant correlations. Inter-rater reliability was determined by percent agreement between graders for dichotomized categories of "quality of DSI is adequate for safe C-TFESI" vs "quality of DSI is inadequate for safe C-TFESI." The percentage of agreement was reported, along with Gwet's agreement coefficient (AC). The intrarater (pre/post) correlation was assessed using Yule's Q statistics.

Results: Correlation coefficients were interpreted as follows: 0.00-0.19 "very weak," 0.20-0.39 "weak," 0.40-0.59 "moderate," 0.60-0.79 "strong," and 0.80-1.00 "very strong." Inter-rater reliability analyses demonstrated that the patient position category had "very strong" agreement, contrast volume had "strong" agreement, and mask image had "moderate" agreement. The overall inter-rater reliability was "moderate." All of the raters demonstrated "very strong" intrarater reliability.

Conclusions: The proposed grading system for adequate-quality DSI during CTFESI showed overall "moderate" and "very strong" inter- and intrarater reliability, respectively. This scheme provides an objective measure of DSI quality for CTFESI. Refinement is needed to improve the reliability of this scheme.
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http://dx.doi.org/10.1093/pm/pnaa032DOI Listing
November 2020

The Magnitude and Duration of the Effect of Intra-articular Corticosteroid Injections on Pain Severity in Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

Am J Phys Med Rehabil 2020 07;99(7):617-625

From the Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland (MS, KL); Department of Interventional Pain Medicine, Providence Medical Institute, Providence Cedars-Sinai Tarzana Hospital, Los Angeles, California (RM); and Department of Physical and Rehabilitation Medicine, University of Utah School of Medicine, Salt Lake City, Utah (ZM).

Objectives: The aims of the study were to clarify the evidence on the magnitude and duration of treatment effect of intra-articular corticosteroid injections for knee osteoarthritis compared with placebo, to evaluate a treatment effect by steroid type, and to describe the reported adverse effects.

Design: Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework.

Results: The final sample included eight randomized controlled studies with follow-ups from 1 to 26 wks. The risk of systematic bias was considered low in five and high in three studies. The pooled standardized mean difference was -0.58 (95% confidence interval = -0.88 to -0.27) and number needed to treat 5.1 (95% confidence interval = 10.0 to 3.7). The heterogeneity was considerable. The pooled effect size approached the level of statistical insignificance at 4 mos. The pooled risk ratio of adverse effects was insignificant 0.95 (95% confidence interval = 0.34 to 2.55).

Conclusions: The intra-articular corticosteroid had a mild to moderate effect on pain severity up to 3 mos after the injection-much longer than it had previously been reported. The effect may vary substantially in different patient groups and appropriate patient selection is important. The risk of adverse effects was low.
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http://dx.doi.org/10.1097/PHM.0000000000001384DOI Listing
July 2020

Annual Maximum Dose of Epidural Steroid Injection.

Pain Med 2019 10;20(10):2069-2070

Columbia University Medical Center, Rehabilitation and Regenerative Medicine, New York, New York, USA.

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http://dx.doi.org/10.1093/pm/pnz191DOI Listing
October 2019

Cumulative Lifetime Steroid Exposure via Epidural Administration.

Pain Med 2019 11;20(11):2323-2324

Rehabilitation and Regenerative Medicine, Columbia University Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1093/pm/pnz203DOI Listing
November 2019

The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data.

Pain Med 2020 03;21(3):472-487

Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.

Design: Comprehensive systematic review.

Outcome Measures: The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.

Results: For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58-68%) at one month, 74% (68-80%) at three months, 64% (59-69%) at six months, and 64% (57-71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43-55%) at one month, 48% (35-61%) at three months, 43% (33-53%) at six months, and 59% (45-73%) at one year, but there was a lack of corroboration from appropriately controlled studies.

Conclusions: There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.
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http://dx.doi.org/10.1093/pm/pnz160DOI Listing
March 2020

Factors associated with willingness to work among unemployed persons with a disability in a large urban area: A short communication.

Work 2018 ;60(4):597-601

Department of Psychological and Vocational Rehabilitation, St. Petersburg Scientific and Practical Center of Medical and Social Expertise, Prosthetics, and Rehabilitation of Disabled N.A. G.A. Albrecht, St. Petersburg, Russian Federation.

Background: One of the reasons for the high unemployment amongst people with disability is a lack of knowledge on factors determining their employment. Factors associated with willingness and attitudes towards work have not been studied sufficiently amongst the general population of people with impaired functioning. Recognizing and improving attitudes to work and vocational rehabilitation may increase the employment rate of persons with disabilities.

Objective: To investigate the influence of some demographic factors on a willingness to work and an interest in vocational rehabilitation amongst unemployed persons with confirmed disability.

Methods: Cross-sectional survey-based study amongst unemployed persons with disabilities in a large urban area. The sample consisted of 1 547 respondents with mostly mild or moderate disabilities. The multinomial logistic regression was used to obtain relative risk ratios (RRs) for different demographic characteristics of the sample.

Results: An interest in vocational rehabilitation was significantly associated with older age (RR 1.36, 95% CI 1.2 to 1.5), lower disability grade (RR 1.30, 95% CI 1.06 to 1.60), and lower expectation of a desired salary (RR 0.77, 95% CI 0.67 to 0.88). Older age (RR 1.31, 95% CI 1.14 to 1.51) and more severe disability (reversed figure - RR 0.75, 95% CI 0.60 to 0.93) were associated with a delayed willingness to work.

Conclusions: Amongst unemployed persons with severe or moderate disabilities, a better willingness to work was mostly associated with younger age and milder disability severity. Older persons with less disabilities and realistic expectations of salary rate reported an interest in vocational rehabilitation more often.
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http://dx.doi.org/10.3233/WOR-182767DOI Listing
January 2019

Corticosteroid Injections Into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial.

Am J Phys Med Rehabil 2018 10;97(10):741-746

From the Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee (DJK, BJS); Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City (LH, JW, JL, MS); Department of Anesthesia & Perioperative Care, Division of Pain Medicine, University of California, San Francisco, San Francisco (RM); and Department of Neurosurgery, Stanford University, Palo Alto (JL), California.

Background: Corticosteroid injections into the intra-articular zygapophysial (z-joints) are frequently used to treat this cause of low back pain. No studies have been done on the efficacy of intra-articular corticosteroids in those with z-joint pain confirmed by dual comparative medial branch blocks.

Objective: The aim of the study was to determine whether an injection of a corticosteroid into lumbar z-joints is effective in reducing pain and the need for radiofrequency neurotomy.

Methods: This is a double-blind, prospective, randomized, placebo-controlled trial. The study was conducted in Academic Medical Center. Twenty-eight subjects with z-joint pain confirmed by medial branch blocks were included in the study. Subjects with confirmed z-joint pain via dual comparative medial branch block were randomized to receive either intra-articular corticosteroid (triamcinolone 20 mg) or saline via fluoroscopic guided injection.

Results: No statistically significant difference in the need for radiofrequency neurotomy (radiofrequency neurotomy) between the groups, with 75% (95% confidence interval = 50.5%-99.5%) of the saline group vs. 91% (95% confidence interval = 62.3%-100%) of the corticosteroid group receiving radiofrequency neurotomy. There is no difference in mean time to radiofrequency neurotomy between saline (6.1 wks) and corticosteroid (6.5 wks) groups. There is a need for radiofrequency neurotomy.

Conclusions: Corticosteroid injections into the lumbar z-joints were not effective in reducing the need for radiofrequency neurotomy of the medial branches in those with z-joint pain confirmed by dual comparative medial branch blocks.
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http://dx.doi.org/10.1097/PHM.0000000000000960DOI Listing
October 2018

Use of pain medication before and after lumbar discectomy: longitudinal analysis of a nation-wide cohort.

Minerva Chir 2018 Jun 1;73(3):280-287. Epub 2018 Feb 1.

Department of Public Health, University of Turku, Turku University Hospital, Turku, Finland.

Background: Previous studies have suggested that variation in results of lumbar discectomy depends on careful selection of patients. Numerous factors have been suggested to explain this variation with no direct examinations on this issue. The objective was to examine the use of pain medication before and after lumbar discectomy in patients with back pain.

Methods: Prospective occupational cohort study (N.=151,618) with linkage to national registers. Of the cohort members, 1538 (age 44 years) underwent discectomy. Records from purchases of pain medication were obtained during a 3-year period before and after hospital discharge.

Results: Purchases of pain medication increased during the follow-up period from 9.7±28.7 to 17.3±17.3 defined daily doses. Three groups were identified: 1) with constant, relatively low pain medication use; 2) with high use combined with further increases in purchases until the time of surgery and only a slight decrease thereafter; and 3) with a sharp rise in medication use before surgery and a return to no pain medication use approximately six months after the discharge. Non-manual profession (OR=1.34, 95% CI: 1.06 to 1.69) and open surgery technique increased (OR=1.32, 95% CI: 1.04 to 1.67) the probability of being included into the third group.

Conclusions: The greater decline in the use of pain medication after discectomy was associated with a sharp rise of that use within six months before surgery. This suggests that lumbar discectomy may benefit especially those with acute or subacute pain within the six-month window.
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http://dx.doi.org/10.23736/S0026-4733.18.07580-6DOI Listing
June 2018

Cervical Epidural Steroid Injection: Techniques and Evidence.

Phys Med Rehabil Clin N Am 2018 02 16;29(1):1-17. Epub 2017 Oct 16.

Division of Physical Medicine and Rehabilitation, University of Utah, 30 N 1900 E, Rm 1C441, Salt Lake City, UT 84132, USA. Electronic address:

Cervical epidural steroid injections are a common treatment of cervical radicular pain. Important safety considerations include attention to the possibility of spinal cord infarction and spinal epidural hematoma. When appropriate, radiographic, technical, and pharmacologic principals are used, these procedures are relatively safe. Cervical epidural steroid injections are effective for the short-term treatment of radicular pain. More rigorously designed clinical outcomes studies of both cervical interlaminar and transforaminal epidural steroid injections are needed.
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http://dx.doi.org/10.1016/j.pmr.2017.08.001DOI Listing
February 2018

Psychometric properties of the neck disability index amongst patients with chronic neck pain using item response theory.

Disabil Rehabil 2018 Sep 13;40(18):2116-2121. Epub 2017 May 13.

a Department of Physical and Rehabilitation Medicine , Turku University Hospital and University of Turku , Turku , Finland.

Objective: The Neck Disability Index (NDI) is commonly used for clinical and research assessment for chronic neck pain, yet the original version of this tool has not undergone significant validity testing, and in particular, there has been minimal assessment using Item Response Theory. The goal of the present study was to investigate the psychometric properties of the original version of the NDI in a large sample of individuals with chronic neck pain by defining its internal consistency, construct structure and validity, and its ability to discriminate between different degrees of functional limitation.

Methods: This is a cross-sectional cohort study of 585 consecutive patients with chronic neck pain seen in a university hospital rehabilitation clinic. Internal consistency was evaluated using Cronbach's alpha, construct structure was evaluated by exploratory factor analysis, and discrimination ability was determined by Item Response Theory.

Results: The NDI demonstrated good internal consistency assessed by Cronbach's alpha (0.87). The exploratory factor analysis identified only one factor with eigenvalue considered significant (cutoff 1.0). When analyzed by Item Response Theory, eight out of 10 items demonstrated almost ideal difficulty parameter estimates. In addition, eight out of 10 items showed high to perfect estimates of discrimination ability (overall range 0.8 to 2.9).

Conclusions: Amongst patients with chronic neck pain, the NDI was found to have good internal consistency, have unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability. Implications for Rehabilitation The Neck Disability Index has good internal consistency, unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability. The Neck Disability Index is recommended for use when selecting patients for rehabilitation, setting rehabilitation goals, and measuring the outcome of intervention.
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http://dx.doi.org/10.1080/09638288.2017.1325945DOI Listing
September 2018

Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Knee Osteoarthritis: Six-Month Outcomes.

Pain Med 2017 Sep;18(9):1631-1641

Department of Anesthesiology.

Objective: Determine outcomes of cooled radiofrequency ablation (C-RFA) of the genicular nerves for treatment of chronic knee pain due to osteoarthritis (OA).

Design: Cross-sectional survey.

Setting: Academic pain medicine center.

Subjects: Consecutive patients with knee OA and 50% or greater pain relief following genicular nerve blocks who underwent genicular nerve C-RFA.

Methods: Survey administration six or more months after C-RFA. Pain numeric rating scale (NRS), Medication Quantification Scale III (MQSIII), Patient Global Impression of Change (PGIC), and total knee arthroplasty (TKA) data were collected. Logistic regression was used to identify factors that predicted treatment success.

Results: Thirty-three patients (52 discrete knees) met inclusion criteria. Thirty-five percent (95% confidence interval [CI] = 22-48) of procedures resulted in the combined outcome of 50% or greater reduction in NRS score, reduction of 3.4 or more points in MQSIII score, and PGIC score consistent with "very much improved/improved." Nineteen percent (95% CI = 10-33) of procedures resulted in complete pain relief. Greater duration of pain and greater than 80% pain relief from diagnostic blocks were identified as predictors of treatment success. The accuracy of the model was 0.88 (95% CI = 0.78-0.97, P  <   0.001).

Conclusions: Genicular C-RFA demonstrated a success rate of 35% based on a robust combination of outcome measures, and 19% of procedures resulted in complete relief of pain at a minimum of six months of follow-up. Report of 80% or greater relief from diagnostic blocks and duration of pain of less than five years are associated with high accuracy in predicting treatment success. Further prospective study is needed to optimize the patient selection protocol and success rate of this procedure.
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http://dx.doi.org/10.1093/pm/pnx069DOI Listing
September 2017

Psychometric properties of the Oswestry Disability Index.

Int J Rehabil Res 2017 Sep;40(3):202-208

aDepartment of Physical and Rehabilitation Medicine bTurku University of Applied Sciences, Turku, Finland cDepartment of Orthopedic Surgery, Physical Medicine and Rehabilitation, Stanford University Hospital and Clinics, Redwood City dDepartment of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of California, San Francisco, San Francisco, California, USA.

The aim of this study was to investigate the psychometric properties of the Oswestry Disability Index (ODI) in a large cross-sectional cohort of individuals with chronic low back pain by defining its internal consistency, construct structure and validity, and its ability to differentiate between different degrees of functional limitation. A total of 837 consecutive outpatient patients with low back pain were studied. The internal consistency of ODI was assessed by Cronbach's α, construct structure by exploratory factor analysis, construct validity by confirmatory factor analysis, and discrimination was determined by item response theory analysis. The ODI showed good internal consistency (α=0.85). Explanatory factor analysis showed that ODI is a unidimensional test measuring functional level and nothing else. The confirmatory factor analysis showed that the standardized regression weights of all ODI items were relatively high, varying from 0.5 to 0.7. The item response theory analysis suggested that eight out of 10 ODI items have a close to perfect ability to measure functional limitations in accordance with the actual severity of disability experienced by the respondents. Discrimination of all the items was high to perfect (1.08-2.01). The test characteristic and test information curves showed that the discriminative ability of the ODI is superior at higher levels of disability. The present data showed that the ODI is an internally consistent, unidimensional scale with overall excellent construct validity and ability to discriminate the severity of functional disability. The analysis suggests that the ODI may better distinguish between the relative degrees of function at above-average disability levels.
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http://dx.doi.org/10.1097/MRR.0000000000000226DOI Listing
September 2017

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections?

Pain Med 2017 Jul;18(7):1326-1333

Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA.

Background: The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI).

Objective: To determine the relationship between BMI and fluoroscopy time during CIESI.

Methods: Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI.

Results: Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P  = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P  = 0.17 and P  = 0.12, respectively).

Conclusions: The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.
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http://dx.doi.org/10.1093/pm/pnw264DOI Listing
July 2017

The effect of body mass index on fluoroscopy time and radiation dose in intra-articular glenohumeral joint injections.

Clin Imaging 2017 Mar - Apr;42:19-24. Epub 2016 Nov 16.

University of Utah, Division of PM&R, Sports Medicine, United States.

Purpose: To determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during fluoroscopy-guided glenohumeral joint injections.

Methods: This was a retrospective analysis of prospectively collected data. Physicians with board certification in Physical Medicine and Rehabilitation and/or Sports Medicine performed or supervised all injections. BMI was calculated within three months of the injection. Fluoroscopy time and radiation dose data were recorded by the fluoroscopy system and transcribed into the clinical database after each procedure.

Results: A total of 335 intra-articular GHJ injections were performed, 230 on the right shoulder and 105 on the left shoulder; none were bilateral. The mean fluoroscopy time for all injections was 18.8±12.6s, and the mean radiation DAP was 656±1190mGy-cm2. There was no significant difference in fluoroscopy time or dose between first-time and repeat injections (P=.405; P=.011) and no significant differences in fluoroscopy time or radiation dose when a trainee was involved (P=.756 for time and P=.149 for dose). Needle lengths of 1.5, 2.5, or 3.5in. were used during the injection, and there was no significant difference in needle length selection between BMI groups (P=.319).

Conclusions: Intra-articular glenohumeral joint injection fluoroscopy time and radiation dose are not affected by body mass index, age, gender, trainee-involvement, first versus repeat injection, or needle length. This procedure is associated with a dose of radiation that likely has minimal to no clinical significance.
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http://dx.doi.org/10.1016/j.clinimag.2016.11.008DOI Listing
April 2017

Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature.

PM R 2017 Jun 22;9(6):603-611. Epub 2016 Oct 22.

Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland(¶).

Objective: To analyze the literature to determine whether controlled studies on percutaneous tenotomy have been published, and if so, to systematically assess the efficacy of percutaneous tenotomy for the treatment of tendinosis at the lateral epicondyle of the elbow.

Design: Systematic review of the available literature.

Methods: Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, and Web of Science databases were searched in November 2015, unrestricted by date. After the initial search, we excluded conference proceedings, theses, reviews, expert opinions, and publications written in languages other than English. Next, 2 independent reviewers screened all of the remaining records with regard to their titles and abstracts, and subsequently, the full texts of identified publications potentially relevant to the present study.

Results: Six articles focused on percutaneous tenotomy, none of which were controlled against a placebo or conservative treatment group. The absence of true randomized controlled trials created a great deal of heterogeneity between the studies; thus we could not include any of our studies in the intended final quantitative analysis with meta-analysis tools. We describe all 6 studies identified by this systematic review with a detailed analysis of the procedural methods, outcome measures, and conclusions of each study.

Conclusions: Percutaneous tenotomy presents an alternative to surgical release of the common extensor tendon for the treatment of chronic tendinosis at the lateral epicondyle of the elbow. Current research supporting the efficacy of this procedure, however, is of low quality (level II to level IV).

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.pmrj.2016.10.012DOI Listing
June 2017

Psychometric Properties of the Pain Numeric Rating Scale When Applied to Multiple Body Regions among Professional Musicians.

PLoS One 2016 7;11(9):e0161874. Epub 2016 Sep 7.

Department of Physical and Rehabilitation Medicine, Turku University Hospital, Turku, Finland, and University of Turku, Turku, Finland.

Background: Despite the broad popularity of a numeric rating scale (NRS) its psychometric properties are not well known. The objective was to determine if there is any difference in the discrimination ability of the NRS when used for measuring pain severity separately in different body regions.

Methods: Cross-sectional survey study of 630 professional musicians. Item Response Theory (IRT) was used to define the psychometric properties of the NRS.

Results: The discrimination ability of the pain NRS was dependent on the body area to which it was applied. The discrimination was low 0.5 (95% CI 0.4. to 0.7) for the hand region and perfect for the shoulder and upper part of the neck- 3.2 (95% CI 1.2 to 5.2) and 10.5 (95% CI 10.0 to 10.9), respectively. Both shoulder and neck NRSs showed a great shift towards higher levels of pain severity meaning that the ability of the NRS to discriminate low levels of pain is poor. NRS scores obtained from all other regions did not demonstrate any discrimination ability.

Conclusions: The pain NRS might have different psychometric properties depending on the body area to which it is applied. Overall, the modest discrimination ability of the pain NRS implies that it should be used in screening questionnaires with some reservations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161874PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5014406PMC
August 2017

Cooled Radiofrequency Ablation of Genicular Nerves for Knee Osteoarthritis Pain: A Protocol for Patient Selection and Case Series.

Anesth Pain Med 2016 Dec 24;6(6):e39696. Epub 2016 Aug 24.

Department of Anesthesiology, Northwestern Feinberg School of Medicine, Chicago, USA.

Background: Chronic knee pain from osteoarthritis (OA) is common in the aging and the obese population. Radiofrequency ablation of the genicular nerves has been introduced as a potential surgery-sparing treatment for chronic knee pain from OA, yet only two outcome studies have been published and optimal patient selection for this procedure has not been established.

Objectives: We describe a standardized protocol for selecting patients for cooled radiofrequency ablation (C-RFA) of the genicular nerves, as well as the clinical outcomes of four patients ages 63-65 years.

Methods: The threshold for selection based on diagnostic genicular nerve block was ≥ 80% pain reduction. Following successful block, C-RFA of the genicular nerves was performed. Outcomes included pain, function, analgesic medication use, opioid use, and progression to total knee arthroplasty at a minimum of 6 month follow up.

Results: C-RFA of the genicular nerves after using the described selection protocol resulted in > 90% pain reduction, improved function and avoidance of surgery at 6 months in all four cases. All opioid and analgesic medication use decreased or was unchanged in all cases. No serious adverse events occurred.

Conclusions: The accompanying case series suggests that this protocol is deserving of randomized, prospective study.
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http://dx.doi.org/10.5812/aapm.39696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5560582PMC
December 2016

Comparing Percutaneous Vertebroplasty and Conservative Therapy for Treating Osteoporotic Compression Fractures in the Thoracic and Lumbar Spine: A Systematic Review and Meta-Analysis.

J Bone Joint Surg Am 2016 Jun;98(12):1041-51

Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland.

Background: Vertebral compression fractures are a common complication of osteoporosis and are often treated by percutaneous vertebroplasty (PVP). The ability of this procedure to relieve pain better than conservative treatment is still debated. The purpose of this study was to compare the degree and duration of pain relief following PVP with that following conservative treatment for osteoporotic compression fractures by means of meta-analysis of randomized controlled trials.

Methods: The CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science databases were queried for randomized controlled trials comparing PVP with conservative treatment or placebo/sham. The methodological quality was assessed according to the Cochrane Collaboration's domain-based evaluation framework. Random-effects meta-analysis of the raw mean difference between groups in change in pain level was performed, with sensitivity analyses and the Egger test for potential publication bias.

Results: Of 209 records found, 11 were considered relevant, involving 1,048 participants. The risk of bias was considered low in 10 studies and high in 1. The 531 patients treated with PVP had a significantly lower pain level compared with the control group at 1 to 2 weeks, 2 to 3 months, and 12 months. The 95% CI (confidence interval) of the pooled effect size at every time interval included the score of 1.5, considered to be the minimal clinically important difference. The largest pooled effect size of -1.4 (95% CI, -2.3 to -0.5) was found during the first 1 to 2 weeks. The heterogeneity was high at all 3 time points (I(2), 71% to 96%). No significant publication bias was detected.

Conclusions: Up to 1 year postoperatively, the effect of PVP exceeded the effect of conservative therapy with respect to pain relief in patients with osteoporotic compression fractures. The effect size was significant and close to the minimal clinically important difference.
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http://dx.doi.org/10.2106/JBJS.15.00425DOI Listing
June 2016

Confirmatory factor analysis of 12-Item World Health Organization Disability Assessment Schedule in patients with musculoskeletal pain conditions.

Clin Rehabil 2017 May 3;31(5):702-709. Epub 2016 Jun 3.

1 Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland.

Objective: To investigate the factor structure of the 12 item World Health Organization Disability Assessment Schedule (WHODAS) 2.0.

Design: Cross-sectional cohort survey study.

Setting: Physical and Rehabilitation Medicine outpatient university clinic.

Subjects: The 408 consecutive patients with chronic musculoskeletal pain.

Main Measures: Exploratory and confirmatory factor analysis.

Results: A two-factor model most accurately fit the observed data of musculoskeletal pain patients (root mean square error of approximation 0.049, relative Chi square value 1.99). Twelve WHODAS 2.0 items were distributed between two factors with covariance between them of 0.8. The first factor contained domains related mostly to physical functioning, while another was associated mostly with social and cognitive functioning. There were a few differences between single items in their importance in defining the variance within these two factors. Of the six International Classification of Functioning, Disability and Health domains belonging to the first construct, the ability to carry out household responsibilities explained most, 84% of the total variance in this construct. For the second factor, the ability to participate in community activities seemed to be the most important, explaining 85% of the total variance in this construct.

Conclusions: In this study, the two-factor structure model of the 12-item WODAS 2.0 demonstrated the most accurate fit within patients with musculoskeletal pain conditions.
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http://dx.doi.org/10.1177/0269215516652930DOI Listing
May 2017

Novel Treatment of Radicular Pain With a Multi-Mechanistic Combination Topical Agent: A Case Series and Literature Review.

Anesth Pain Med 2016 Apr 1;6(2):e33322. Epub 2016 Mar 1.

Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago, Northwestern Feinberg School of Medicine, Chicago, USA; Department of Anesthesiology, Northwestern Feinberg School of Medicine, Chicago, USA.

Introduction: Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence. While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7).

Case Presentation: Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient's baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases.

Conclusions: This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.
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http://dx.doi.org/10.5812/aapm.33322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886452PMC
April 2016

Ranges of motion after reverse shoulder arthroplasty improve significantly the first year after surgery in patients with rheumatoid arthritis.

Eur J Orthop Surg Traumatol 2016 Jul 19;26(5):447-52. Epub 2016 May 19.

Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland.

Objectives: To evaluate the trajectory of the change in range of motion after reverse shoulder joint replacement during 3-year follow-up among patients with rheumatoid arthritis.

Methods: Retrospective cohort longitudinal study of 76 shoulder replacements performed in a university clinic. The range of shoulder motion was assessed by a physiotherapist using a manual goniometer with 5-degree precision before the surgery and 1, 3, 6, 12, and 36 months postoperatively.

Results: The shapes of the regression curves suggest that the improvement or decline observed in joint motion was happening mostly during the first year after surgery. After 1 year, the trajectories become flat and they remained unchanged until the end of follow-up.

Conclusions: After shoulder joint replacement, the range of shoulder motion showed substantial changes during the first year only. This should be taken into account when scheduling control visits, planning rehabilitation, and predicting the use of community services after the surgery.
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http://dx.doi.org/10.1007/s00590-016-1795-6DOI Listing
July 2016

Safety of epidural steroid injections.

Expert Opin Drug Saf 2016 Aug 13;15(8):1031-9. Epub 2016 May 13.

a Department of Orthopedics, Division of Physical Medicine and Rehabilitation , Stanford University , Redwood City , CA , USA.

Introduction: Epidural steroid injections (ESI) are a commonly utilized treatment for cervical and lumbar radicular pain. All medical procedures and medications carry an inherent level of risk, that must be balanced with the effectiveness of the treatment to determine the risk to benefit ratio for a patient.

Areas Covered: This article will outline the risks of ESIs and in doing so help shed light on the procedural risks versus the risks of the medication. Additionally, it will help differentiate minor adverse events from significant permanent complications.

Expert Opinion: Catastrophic complications of ESI such as paralysis and stroke unquestionably warrant the recent increased attention given to the safety of these injections. While a single major complication is unacceptable, the relative rate of these major complications must be put in prospective. The true rate is small enough that it is impossible to calculate. All cases are limited to case reports and not detected in even the largest published cohorts of ESI. Moreover, recent advances in medication selection and technique have further reduced the incidence of these very rare complications. Conversely, the more common adverse events are rather minor, generally transient, and mostly occur at incidences of less than 1%.
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http://dx.doi.org/10.1080/14740338.2016.1184246DOI Listing
August 2016

The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections.

Spine J 2016 07 22;16(7):876-83. Epub 2016 Mar 22.

Department of Physical Medicine & Rehabilitation (PM&R), Northwestern Feinberg School of Medicine/The Rehabilitation Institute of Chicago, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 345 East Superior St, Chicago, IL 60605, USA.

Objective: Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs.

Design: A retrospective study design was used.

Setting: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician.

Participants: Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose.

Interventions: All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded.

Main Outcome Measures: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01.

Results: A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001).

Conclusions: The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time.
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http://dx.doi.org/10.1016/j.spinee.2016.03.041DOI Listing
July 2016