Selections From This Month in the Archives

Article Outline

• The Relationship Between Repeated Epidural Steroid Injections and Subsequent Opioid Use and Lumbar Surgery
• Influence of Hand Cycling on Physical Capacity in the Rehabilitation of Persons With a Spinal Cord Injury: A Longitudinal Cohort Study
• A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care?
• A Systematic, Critical Review of Manual Palpation for Identifying Myofascial Trigger Points: Evidence and Clinical Significance

Janna Friedly, MD

Isuta Nishio, MD, PhD

Michael J. Bishop, MD

Charles Maynard, PhD

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The Relationship Between Repeated Epidural Steroid Injections and Subsequent Opioid Use and Lumbar Surgery 

The use of epidural steroid injections (ESIs) in the treatment of pain of lumbar origin remains contentious. Friedly and colleagues examine an aspect of this debate in a study of more than 13,000 Department of Veterans Affairs patients who received lumbar ESIs over a 2-year period. While the study has limitations that include its retrospective nature and the male preponderance of its sample population, the findings are interesting. Most strikingly, the effect of opioid use differed little from that of ESIs: 64% of the patients were using opiods prior to injection and 67% continued to use them after injection. Patients receiving more than 3 injections were more likely to undergo lumbar surgery after ESI (7.6% vs 6.1%, P=.005) than those receiving fewer injections. More research is needed but these results will add more fuel to the controversy. • SEE PAGE 1011

Linda J. Valent, MSc

Annet J. Dallmeijer, PhD

Han Houdijk, PhD

Hans J. Slootman, MD

Marcel W. Post, PhD

Lucas H. van der Woude, PhD

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Influence of Hand Cycling on Physical Capacity in the Rehabilitation of Persons With a Spinal Cord Injury: A Longitudinal Cohort Study 

Valent and colleagues assessed the effectiveness of upper-extremity hand cycling in an observational study of 162 people with acute spinal cord injury. Peak oxygen uptake (Vo₂peak), power output (POpeak), and upper-extremity strength were assessed at the beginning of inpatient rehabilitation, at discharge, and in follow-up, 1 year later. The investigators found that during inpatient rehabilitation, Vo₂peak, POpeak, and elbow extension strength increased in subjects with paraplegia who cycled relative to their peers that did not, whereas no changes were found among those with tetraplegia at or below the C5 vertebra. No further changes of the outcome measures were found in either group during the follow-up period. Effects on daily activities and function were not assessed and the authors believe that a randomized controlled trial is now warranted. • SEE PAGE 1016

Leighton Chan, MD, MPH

Marcia A. Ciol, PhD

Anne Shumway-Cook, PhD

Kathryn M. Yorkston, PhD

Brian J. Dudgeon, PhD

Steven M. Asch, MD, MPH

Jeanne M. Hoffman, PhD

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A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care? 

Although disability is a known risk factor for inadequate health care, most of the work supporting this knowledge is derived from cross-sectional investigations and self-reported measures of care. Chan and colleagues performed a multiyear longitudinal cohort study of nearly 30,000 Medicare patients and found, regardless of disability status, that less than half of the patients had received appropriate treatment or evaluation for a variety of indications, ranging from iron deficiency anemia to angina and eye care in diabetes. Disability status was a significant factor in several of the measures. Compared with people with no disability, those with some level of disability were less likely to have a mammogram or an eye examination, and more likely to experience an important avoidable outcome. The authors conclude that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories, but that its impact varies depending on the indicator. • SEE PAGE 1023

Corrie Myburgh, PhD

Anders Holsgaard Larsen, PhD

Jan Hartvigsen, PhD

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A Systematic, Critical Review of Manual Palpation for Identifying Myofascial Trigger Points: Evidence and Clinical Significance 

The December 2007 and January 2008 issues of Archives included 2 articles, the first by Chen and colleagues (p 1658) and the second by Shah and colleagues (p 16), that highlighted the progress being made in our abilities to quantify the physical and biochemical characteristics of myofascial pain. Myburgh and colleagues add to these efforts with a systematic review that assesses the capability of manual palpation to identify trigger points in a reproducible manner. Reproducibility is low. Using the guidelines of the STAndards for the Reporting of Diagnostic accuracy studies (STARD), the investigators found that the available studies tended to be of poor quality and provided only a moderate level of evidence of reproducibility for only local tenderness of the trapezius (κ range, .15—.62) and pain referral to the gluteus medius (κ range, .30—.49) and quadratus lumborum (κ range, .36—.50). The authors concluded that the methodologic quality of the studies designed to assess trigger point reproducibility is typically poor and that more, higher quality investigations were needed. • SEE PAGE 1169