Analysis of balance in adults with chronic axial spinal pain receiving medial branch block or radiofrequency ablation procedures.

BackgroundIn addition to a range of functional impairments seen in individuals with a lower-limb amputation, this population is at a substantially elevated risk of falls. Studies postulate that the lack of sensory feedback from the prosthetic limb contributes heavily to these impairments, but the extent to which sensation affects functional measures remains unclear. Research questionThe purpose of this study is to determine how sensory impairments in the lower extremities relate to performance with common clinical functional measures of balance and gait in individuals with a lower-limb amputation. Here we evaluate the effects of somatosensory integrity to clinical and lab measures of static, reactive and dynamic balance, and gait stability. MethodsIn 20 individuals with lower-limb amputation (AMP) and 20 age and gender-matched able-bodied controls (CON), we evaluated the effects of sensory integrity (pressure, proprioception, and vibration) on measures of balance and gait. Static, reactive, and dynamic balance were assessed using the Sensory Organization Test (SOT), Motor Control Test (MCT), and Functional Gait Assessment (FGA), respectively. Gait stability was assessed through measures of step length asymmetry and step width variability. Sensation was categorized into intact or impaired sensation by pressure thresholds and differences across groups were analyzed. ResultsThere were significant differences between AMP and CON groups for reliance on vision for static balance in the SOT, MCT, and FGA (p < 0.01). Despite differences across groups, there were no significant differences within the AMP group based on intact or impaired sensation across all functional measures. SignificanceDespite being able to detect differences between able-bodied individuals and individuals with an amputation, these functional measures cannot distinguish between levels of impairment within participants with an amputation. These findings suggest that more challenging and robust metrics are needed to evaluate the effects of sensation and function in individuals with an amputation.

Chronic axial spinal pain is a leading cause of disability and healthcare spending in the United States. A common source of axial spinal pain is the facet joint. Current treatments for facet joint-mediated pain include conservative treatments and interventions such as intra-articular facet joint injections (FJI), medial branch blocks (MBB), and radiofrequency ablation (RFA). While facet joint interventions are one of the most common spinal procedures, current scientific literature demonstrates conflicting results regarding the use of corticosteroids in these interventions. A systematic review was conducted to determine the efficacy of local corticosteroid usage in facet joint interventions for treating chronic axial spinal pain. Separate literature searches were performed using PubMed, Google Scholar, Embase, and Cochrane Library to evaluate the use of local corticosteroids in intra-articular FJI, MBB, and for the prevention of post-neurotomy neuritis (PNN). Inclusion criteria included a randomized clinical trial (RCT) or control trial while unique inclusion criteria was used for the differing uses of local corticosteroids. The exclusion criteria for studies included (i) studies written in a non-English language; (ii) articles without full-text access or abstract-only papers; (iii) and studies focused on non-human subjects. Final literature searches were conducted in August 2024. Two studies with 131 patients, four studies with 440 patients, and two studies with 203 patients were selected for the assessment of local corticosteroid use on intra-articular FJI, MBB, and PNN, respectively. A quality assessment tool recommended by The Cochrane Collaboration was used to assess bias risk in included studies. Results were synthesized through a meta-analysis to evaluate intra-articular FJI while a literature analysis was completed to investigate MBB and PNN. This study found that the use of corticosteroid intra-articular FJI and MBB provides significant improvement in pain relief and functionality from baseline for the treatment of lower back pain and chronic axial spinal pain, respectively. However, the use of corticosteroids post-RFA has not been proven to reduce the occurrence of PNN. Limitations to the studies used included blinding bias, absence of placebo groups, subjective inclusion criteria, limited generalizability and small sample sizes.

To compare biomechanics force platform measurements of postural sway with clinical measures of balance and mobility, in frail elderly residents of community nursing homes, in terms of feasibility, correlation with other known risk factors for falls, and intercorrelation with each other. Cross-sectional study. Twelve Tennessee community nursing homes. Of 1315 residents 360 (> or = 65) could stand independently (> or = 10 seconds). Of these eligible subjects, 303 (84%) provided informed consent and were assessed. The biomechanics force platform measurements were postural sway during quiet standing characterized as elliptical area and mean velocity. The clinical measures were functional reach, mobility maneuvers (adapted from Tinetti's Mobility Index), timed chair stands, and 10-foot walk. Resident characteristics and function were also obtained. Balance measurements were obtained on most (100% for postural sway to 67% for chair stand) consenting residents and were reliable on test-retest (intraclass correlation from .56 to .98). Performance in both groups of balance measures deteriorated with increasing musculoskeletal disability. Functional reach and mobility maneuvers correlated with height, and mobility maneuvers with depressive symptoms. Elliptical area correlated with mean velocity of postural sway (Pearson's r = 0.72; P < 0.001), and the clinical measures of balance (functional reach, mobility maneuvers, timed chair stands and walk) were modestly intercorrelated (r from 0.35 to 0.65; all P values < or = 0.05). However, the biomechanical measures were not correlated with the clinical measures. Standard measures of balance were obtained reliably from nursing home residents who could stand independently for > or = 10 seconds. However, in this group, further research is needed to determine which measures best predict falls. Further research is also needed to identify predictors of falls in the majority of residents who were too frail to undergo these standard assessments.

Purpose/Hypothesis: Limited community ambulation is a common occurrence following stroke and is associated with limited participation in activities of daily living. The skills and factors affecting community ambulation following stroke are largely unknown. This study measured participation in community mobility among survivors of stroke and examined the relationship between clinical measures of sensation, strength, balance, and gait and participation in community mobility in order to identify factors constraining community ambulation following stroke. Number of Subjects: Twenty-five adults diagnosed with stroke (mean age 68 ± 9; mean time since stroke 40 mos, independent ambulators with devices) and 25 older adults (mean age 68 ± 11) without stroke participated. Materials/Methods: Level of participation in community ambulation was determined by self reported number of trips and walking related activities performed over a 12 day period (72 hour recall trip activity log completed once a week for four weeks). Clinical measures included the Berg Balance Test (BBT), 10m gait velocity, and Dynamic Mobility Evaluation (DYME) (a new measure of locomotor adaptation), dynamometer measures of lower extremity (LE) strength, goniometric measures of LE range of motion, ankle spasticity, and LE sensation (light touch and proprioception). Results: Participation in community mobility following stroke was characterized by equivalent number of trips into the community, but fewer walking related activities per trip, as compared to adults without stroke. Gait velocity and BBT were significantly (p<.001) worse in the subjects with stroke, and correlated with number of walking related activities (r=.508, p<.01) but not number of trips into the community. Compared to healthy controls, subjects with stroke walked significantly slower on all complex walking tasks in the DYME, however there was considerable variability across tasks. Some tasks (stairs and obstacles) consistently affected gait velocity in all subjects with stroke, while others (load and talk) did not. Impairments in plantarflexion and hip abduction strength in the paretic limb correlated with community ambulation (activities per trip), while spasticity, range of motion and lower extremity sensation were not. Conclusions: This study suggests the impact of stroke on community ambulation is variable. Clinical measures of balance, strength (plantarflexor and hip abduction) and gait velocity are related to level of participation in community ambulation, specifically the number of walking activities performed per trip. Performance of complex walking tasks requiring locomotor adaptation was globally impacted by stroke, but the degree of impact varied by task. Clinical Relevance: Recovery of community ambulation is influenced by many factors following stroke, including balance, strength and usual gait speed. Task specific training to improve the ability to adapt gait to environmental challenges encountered during community ambulation may be a particularly important aspect of mobility training following stroke.

The efficacy of Tai Chi (TC) to improve neuromuscular response characteristics underlying dynamic balance recovery in balance-impaired seniors at high risk for falling was examined during perturbed walking. Twenty-two subjects were randomized into TC or control groups. Nineteen subjects (68-92 years, BERG 44 or less) completed the study. TC training incorporated repetitive exercises using TC's essential motor/biomechanical strategies, techniques, and postural components. Control training used axial exercises, balance awareness/education and stress reduction. Groups trained 1.5 h/day, 5 days/week for 3 weeks. After post-testing, controls received TC training. Subjects walked across a force plate triggered to move forward 15 cm at 40 cm/s at heelstrike. Tibialis anterior and medial gastrocnemius responses during balance recovery were recorded from electromyograms. Four clinical measures of balance were also examined. TC subjects, but not controls, significantly reduced tibialis anterior response time from 148.92 +/- 45.11 ms to 98.67 +/- 17.22 ms (p < or = 0.004) and decreased co-contraction of antagonist muscles (p < or = 0.003) of the perturbed leg. All clinical balance measures significantly improved after TC. TC training transferred to improved neuromuscular responses controlling the ankle joint during perturbed gait in balance-impaired seniors who had surgical interventions to their back, hips, knees and arthritis. The fast, accurate neuromuscular activation crucial for efficacious response to slips also transferred to four clinical measures of functional balance. Significant enhancement was achieved with 3 weeks of training.

The objective of this study was to evaluate whether, after a task-oriented exercise program, the changes in clinical measures of balance and mobility were paralleled by changes in biomechanical parameters in subjects with chronic stroke. Ten stroke subjects took part in an 8-wk exercise program aimed at improving balance and mobility through various functional tasks. Subjects were evaluated before and after the exercise intervention. Clinical measures included the Berg Balance Scale and the Timed-Up-and-Go and laboratory measures included ground reaction forces and center of pressure displacement during four functional tasks. Stroke subjects showed significant improvements (P < 0.05) in the clinical measures after completing the exercise program. Significant improvements (P < 0.05) were also found in postural steadiness during tandem stance and stool touch and in force production through the paretic lower limb during sit-to-stand. This last result was strongly correlated (r = -0.93) with the improvements on the Timed-Up-and-Go after exercise intervention. In contrast, the increase in postural steadiness was poorly correlated with the improvements on the Berg Balance Scale. A task-oriented exercise program might improve both clinical and laboratory measures of balance and mobility in stroke subjects. However, several correlations between the changes in clinical and laboratory measures after exercise intervention were generally weak, indicating that these outcome measures assessed different components of improvements.

Postural control declines with aging and is an independent risk factor for falls in older adults. Objective examination of balance function is warranted to direct fall prevention strategies. Force platform (FP) systems provide quantitative measures of postural control and analysis of different aspects of balance. The purpose of this study was to examine the reliability and validity of FP measures in healthy older adults. This study enrolled 46 healthy elderly adults, mean age 67.67 (5.1) years, who had no history of falls. They were assessed on 3 standardized tests on the NeuroCom Equitest FP system: limits of stability (LOS), motor control test (MCT), and sensory organization test (SOT). The test battery was administered twice within a 10-day period for test-retest reliability; intraclass correlation coefficients (ICCs), standard error of measurement (SEM), and minimal detectable change based on a 95% confidence interval (MDC95) were calculated. FP measures were compared with criterion clinical balance (Mini-BESTest and Functional Gait Assessment) and gait (10-m walk and 6-minute walk) measures to examine concurrent validity using Pearson correlation coefficients. Multiple linear regression analysis examined whether age and activity level were associated with FP performance. The α level was set at P < .05. SOT composite equilibrium scores, MCT average latency, and LOS end point excursion measures all demonstrated excellent test-retest reliability (ICC = 0.90, 0.85, and 0.77, respectively), whereas moderate to good reliability was found for SOT vestibular ratio score (ICC = 0.71). There was large variability in performance in this healthy elderly cohort, resulting in relatively large MDC95 for these measures, especially for the LOS test. Fair correlations were found between LOS end point excursion and clinical balance and gait measures (r = 0.31-0.49), and between MCT average latency and gait measures only (r =-0.32). No correlations were found between SOT measures and clinical balance and gait measures. Age was only marginally significantly (P = .055) associated with LOS end point excursion but was not associated with SOT or MCT measures, and activity level was not associated with any of the FP measures. FP measures provided reliable information on balance function in healthy older adults; however, small learning effects were evident, particularly for the SOT. The SEM and MDC95 for the LOS and SOT measures were relatively large for this healthy elderly cohort. A relationship between FP measures, which assess underlying balance mechanisms, and clinical balance and gait measures was not strongly supported in this study. Further research is needed to justify the value of adding FP measures to a test battery for balance assessment in older adults without a history of falls.

Introduction Medial branch nerve block (MBB) and facet joint injections (FJIs) can be used to manage axial low back pain. Although there have been studies comparing the MBB and FJI effects, a few studies have compared the therapeutic effects of both interventions combined with each separate intervention. This study aimed to compare the pain relief effect of MBB, FJI, and combined treatment with MBB and FJI in patients with axial low back pain. Methods We conducted a retrospective review of patients with axial low back pain who had chart records of the Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) scores measured before treatment and within 6 weeks after treatment. The proportion of patients with successful responses (>30%) was calculated and is presented with Wald confidence intervals. Results We included 66 patients (33, 17, and 16 patients in the MBB, FJI, and combined treatment with MBB and FJI groups). All the patient groups showed significant posttreatment improvements in the NRS [(proportion >30% decrease: MBB 24.2% (9.6–38.9), FJI 29.4% (7.8–51.1), and MBB + FJI 25.0% (3.8–46.2)] scores and the ODI [proportion >30% decrease: MBB 39.4% (22.7–56.1), FJI 23.5% (3.4–43.7), and MBB + FJI 37.5% (13.8–61.2)] scores. Furthermore, there was no significant among-group difference in the ODI and NRS scores. Conclusion MBB, FJI, and combined treatment with MBB and FJI can reduce axial low back pain and improve secondary functional degradation. Although combined treatment with MBB and FJI required a longer intervention time, it did not have a pain relief effect superior to that of MBB or FJI alone.

BackgroundThe FRAX® algorithm quantifies a patient’s 10-year probability of a hip or major osteoporotic fracture without taking an individual’s balance into account. Balance measures assess the functional ability of an individual and the FRAX® algorithm is a model that integrates the individual patients clinical risk factors [not balance] and bone mineral density. Thus, clinical balance measures capture aspects that the FRAX® algorithm does not, and vice versa. It is therefore possible that combining FRAX® and clinical balance measures can improve the identification of patients at high fall risk and thereby high fracture risk.Our study aim was to explore whether there is an association between clinical balance measures and fracture prediction obtained from FRAX®.MethodA cross-sectional study design was used where post hoc was performed on a dataset of 82 participants (54 to 89 years of age, mean age 71.4, 77 female), with a fall-related wrist-fracture between 2008 and 2012. Balance was measured by tandem stance, standing one leg, walking in the figure of eight, walking heel to toe on a line, walking as fast as possible for 30 m and five times sit to stand balance measures [tandem stance and standing one leg measured first with open and then with closed eyes] and each one analyzed for bivariate relations with the 10-year probability values for hip and major osteoporotic fractures as calculated by FRAX® using Spearman’s rank correlation test.ResultsIndividuals with high FRAX® values had poor outcome in balance measures; however the significance level of the correlation differed between tests. Standing one leg eyes closed had strongest correlation to FRAX® (0.610 p = < 0.01) and Five times sit to stand was the only test that did not correlate with FRAX® (0.013).ConclusionThis study showed that there is an association between clinical balance measures and FRAX®. Hence, the use of clinical balance measures and FRAX® in combination, might improve the identification of individuals with high risk of falls and thereby following fractures. Results enable healthcare providers to optimize treatment and prevention of fall-related fractures.Trial registrationThe study has been registered in Clinical Trials.gov, registration number NCT00988572.

We present the case of a patient undergoing lumbar spine decompression for stenosis with a history of Mounier-Kuhn syndrome. The patient presented with axial lumbar spine pain over 6 months...

Clinical measures of balance in people with type two diabetes: A systematic literature review

96. Dual medial branch blocks and progression to radiofrequency neurotomy for zygapophysial arthropathy

We sought an optimal medial branch block (MBB) cutoff value for both single and double MBB protocols that would best correlate with a positive outcome of medial branch neurotomy (MBN). We analyzed the percentage of subjective pain relief following MBB, confirmed by numerical rating scale (NRS) in aggravating positions before and 45 minutes after MBB. The percentage of overall pain relief following MBB was plotted against the following outcome variables: degree of subjective pain relief, duration of relief, patient satisfaction and activity level, no other doctor's visits, and reduction in medications use. Using the percent of pain relief post-MBB plotted in 10% increments in the double-MBB group, patients reporting 70% or greater pain relief following MBB showed statistically favorable outcome for the following four criteria: percentage of pain relief, duration of relief, patient satisfaction, and pain medications reduction. In the single MBB group, patients reporting 80% or greater pain relief following MBB had favorable outcomes for improvement in activity level and patient satisfaction. The double MBB protocol better correlated with favorable MBN outcomes compared with a single MBB protocol. Using a double MBB protocol, a 70% cutoff value for reported subjective pain relief post-MBB best predicted overall outcome following MBN. Without a confirmatory MBB, an 80% cutoff value was the optimal value.

This study compares 2 pain intensity metrics, calculated percentage pain reduction (CPPR) and patient-reported percentage pain reduction (PRPPR), in patients undergoing medial branch nerve blocks (MBB) to determine their comparability and agreement. A retrospective review of prospectively enrolled consecutive MBB patients with axial spine pain from multiple centers. Data were collected via self-report pain diaries and analyzed using linear regression models, concordance correlation coefficients (CCC), and Bland-Altman plots. One hundred and fifty pain diaries yielded 1182/1350 (88%) valid comparisons between CPPR and PRPPR. The CCC was lowest immediately and at 0.5 hours post-injection (0.44 and 0.47) and ranged from 0.58 to 0.62 at later times. Precision, measuring correlation, was poor, while accuracy, measuring the degree of deviation from perfect agreement, was greater than 0.90. Bland-Altman plots showed PRPPR indicated greater pain relief than CPPR at all times, with bias decreasing as pain relief increased. Agreement was higher at 0% and 100% improvement compared to 50% on Bland-Altman plots. The CCC ranged from 0.44 to 0.62 between PRPPR and CPPR in patients with chronic axial pain undergoing diagnostic MBB. PRPPR scores showed greater pain relief than CPPR scores, especially over time. Agreement was higher at extremes of pain relief, while partial average pain relief demonstrated less agreement. Clinicians should therefore not assume equivalence between CPPR and PRPPR. More importantly, there is significant variability in how a patient is categorized for MBB success depending on the measure employed.

Background and Aims:Lumbar facet joint related pain is reported to have a prevalence of 15-45%.This prospective study was conducted to compare the efficacy of medial branch block with medial branch radiofrequency(RF) ablation in patients with lumbar facet joint pain.Methods:Forty-six participants were randomised to Group-I (n=24) or Group-II (n=22). In Group-I, patients received fluoroscope guided medial branch block with 2ml drug solution comprising of 0.25% bupivacaine plus 10mg of triamcinolone and in Group-II, patients received fluoroscope guided medial branch radiofrequency ablation at a temperature of 80°C for 90 seconds using a RF generator. Patients were followed up for a period of three months. Numeric Rating Scale (NRS) Oswestry Disability Index (ODI) and Roland-Morris Questionnaire (RMQ) score were compared between the groups.Results:NRS and ODI scores were found comparable between the two groups at all the time intervals (p>0.05). Significant reduction (RMQ score was found in Group-II at two weeks (p=0.003) and at one month (p=0.01) ; whereas, at two months and three months the scores were found comparable between the groups(p>0.05). Pain at injection/RF site was significantly less in Group-II (p=0.006). None of the patients reported any serious complications.Conclusion:Both medial branch block and medial branch radiofrequency ablation provide good pain relief and improvement of disability in patients with lumbar facet joint pain. However, improvement in disability is early with medial branch radiofrequency ablation.