Line In The Sand

[stim4u]

I give combined grand rounds yearly, and the neurologists always like to slam surgery and pain management with references to conchrane data base. I stand up for my lecture right afterwards, and state there are many sources that doctors refer to. If I used only the conchrane data base, I would have essentially nothing to offer you today. Instead I use a consortium of practice management guidelines, ie ISIS, national clearing house, WC, medicare, etc. Patient like this approach better....

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[101N]

I give combined grand rounds yearly, and the neurologists always like to slam surgery and pain management with references to conchrane data base. I stand up for my lecture right afterwards, and state there are many sources that doctors refer to. If I used only the conchrane data base, I would have essentially nothing to offer you today. Instead I use a consortium of practice management guidelines, ie ISIS, national clearing house, WC, medicare, etc. Patient like this approach better....

I once attended a series of talks during which two spine surgeons were scheduled back to back. The first was a guy known to be a non-believer - Stan Bigos - and he gave his "Spine
Surgery is Way Over-utilized" talk. The next guy up is was an academic traumatologist - Jens Chapman - and the first words out of his mouth were "And now for the non-nihilistic approach".

 

[epidural man]

Give me the article and I will have a look. I am a believe in SCS in the non-work comp realm. But, my experience is that it is a palliative endeavor, not rehabilitative. By that I mean that doesn't improve return to work, functional status (SF-36, or ODI), and meta-analyses have shown - last year's NANS - that it doesn't diminish opioid use.

Here is the article (too big to attach PDF)

http://thejns.org/doi/full/10.3171/JNS/2008/108/2/0292

You are right. At second look at the article, patients didn't have functional improvement when compared to control, however, at five years they did have improved GPE, improved pain scores, and essentially a high satisfaction rate.

At 2 years, cost savings are the same as conventional therapy (the break even point) and at 3 years, there are cost savings.

A few interesting points about the article however. First of all, I find it interesting that 2 patients in the control side had complete resolution of symptoms (and each accounted for two so that is like 4 of them getting better spontaneuously.) I don't know about you, but I think that is very strange and outlier-ish. Second, the authors chose to use the post SCS trial scores for analysis rather than pre trial scores...that is another odity but it also scews the data away from significance - which by the way was at a P value of 0.06. The authors make this silly statement "and is no longer significant at 3 years of follow-up" - regarding pain.

Are you serious? So what you are telling me mr author, is that the arbitrary number you magically picked of 0.05 IS significant, but since you picked 0.05, that means 0.06% isn't significant?

Researchers.....blah. Stupid stupid researchers.

I agree it is a small study, but it is better data than mental health and physical therapy and OT with CRPS - and we insist on that right? (I know, I know....graded motor imagery has class I evidence...but who really does that? I don't think I've ever even met a physical therapist that knew what that was.)

 

[Tenesma]

work comp... that should be a completely different thread... >95% have no desire to EVER go back to work...

a chiropractor once told me he had the perfect test to find out if somebody was going to improve on work-comp: if they loved their job, their co-workers, then odds are higher for return to function...

 

[hyperalgesia]

Probably more accurate to see if they are able to do more of what they enjoy. You could do a study and only include participants who had an activity that they really enjoy but can't do now. Then see what happens after treatment.

Return to work is more acurately an indicator of (work lifestyle) / (home lifestyle).

Home lifestyle = freedom, cash payments, an xbox, etc.
Work lifestyle = a demanding boss, low pay, etc.

Pain management is a footnote.

 

[PMR 4 MSK]

I've seen studies concluding that the workers at highest risk for injury on the job are those with the lowest job satisfaction, and not surprisingly, those same people had the lowest return to work rate.

Work injury has nothing to do with heavy lifting, repetitiveness or similar, and everything to do with psych.

 

[ghost dog]

I've seen studies concluding that the workers at highest risk for injury on the job are those with the lowest job satisfaction, and not surprisingly, those same people had the lowest return to work rate.

Work injury has nothing to do with heavy lifting, repetitiveness or similar, and everything to do with psych.

Here's another study on opioid dosing and mortality:

Two-year opioid-related mortality rates were 1.63 per 1000 population (95%confidence interval [CI] 1.42-1.85) among people with moderate-dose prescriptions, 7.92 per 1000 population (95% CI 5.25-11.49) among those with high-dose prescriptions, and 9.94 per 1000 population (95% CI2.78-25.12) among those with very-high-dose prescriptions.

NOTE: moderate dose : 0 – 200 mg of daily MED

High dose : 201 – 400 daily MED

Very high dose: > 400 daily MED


Open Med. 2011;5(1):e13-22. Epub 2011 Jan 25.

Trends in opioid use and dosing among socio-economically disadvantaged patients.

Gomes T, Juurlink DN, Dhalla IA, Mailis-Gagnon A, Paterson JM, Mamdani MM.

Source

SunnybrookHealth Sciences Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N [email protected]

 

[Jitter Bug]

work comp... that should be a completely different thread... >95% have no desire to EVER go back to work...

a chiropractor once told me he had the perfect test to find out if somebody was going to improve on work-comp: if they loved their job, their co-workers, then odds are higher for return to function...

Agree 100%. Oddly enough it seems the actual injury is irrelevant in a person who is motivated to return to their job. They all get better.

I think this correlates with some of our non-work comp patients, only their life is their job. Do you want to get better to hang with your spouse, kids, go to the gym, watch the game, or do you hate your life and choose instead to be knocked out on opiates in your bedroom with the door closed?