Preoperative education for lumbar radiculopathy: A survey of US spine surgeons

Rehabilitation and lumbar surgery: the French recommendations for clinical practice

BACKGROUND

Indications and techniques of rehabilitation differ widely across types of lumbar surgery, including timing (before or after surgery) and prescriptions (surgeons but also medical or paramedical professionals).

OBJECTIVES

This project aimed to build consensual recommendations for practice in this context.

METHODS

The SOFMER methodology was used to establish recommendations for physical medicine and rehabilitation: a steering committee defined the types of lumbar surgery involved and developed the main questions to be addressed; a scientific committee performed a literature review for grading evidence and proposed the first version of recommendations, which were discussed during a dedicated session at the national Physical and Rehabilitation Medicine congress; then an e-Delphi method with cross-professional experts was used to finalise recommendations and reach a multidisciplinary consensus.

RESULTS

The main questions developed were the value of rehabilitation before and after surgery, timing and type of rehabilitation, benefit of supervision and instrumental rehabilitation, value of patient education, and complementary interventions concerning rehabilitation for discectomy, fusion, and disc prosthesis (excluding decompression for spinal stenosis). The literature review identified 60 articles, but for several of the questions, no article in the literature addressed the issue. The multidisciplinary scientific committee analysed the literature and addressed the questions to propose the first version of a set of 23 recommendations. The congress session failed to answer all questions or to reach consensus for all items. After a three-step e-Delphi, 20 recommendations were retained, for which consensus among experts was reached. The recommendations are applicable only to patients without a neurological lesion.

CONCLUSIONS

These recommendations provide important and consensual knowledge to assist clinicians in decision-making for rehabilitation in lumbar surgery. Despite many of the recommendations relying exclusively on expert opinion rather than published evidence, this approach is an important advance to improve concordance among healthcare professionals.

Pain neuroscience education: Which pain neuroscience education metaphor worked best?

BACKGROUND

The use of pain neuroscience education (PNE) has been shown to be effective in reducing pain, improving function and lowering fear and catastrophisation. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. To date no individualised study has looked at which stories and metaphors may be the most effective in achieving the positive outcomes found with the use of PNE.

OBJECTIVES

This study examined patient responses to the usefulness of the various stories and metaphors used during PNE for patients who underwent surgery for lumbar radiculopathy.

METHOD

Twenty-seven participants who received preoperative PNE from a previous randomised control trial (RCT) were surveyed 1-year post-education utilising a 5-point Likert scale (0 - 'do not remember', 4 - 'very helpful') on the usefulness of the various stories and metaphors used during the PNE session. Participant demographics and outcomes data (pain intensity, function and pain knowledge) were utilised from the previous RCT for analysis and correlations.

RESULTS

Nineteen surveys were returned for a response rate of 70%. No story or metaphor mean was below 2 - 'neutral', lowest mean at 2.53; 6 of the 11 stories or metaphors scored a mean above 3 - 'helpful'.

CONCLUSION

No individual story or metaphor stood out as being predominately important in being helpful in the recovery process through the use of PNE.

CLINICAL IMPLICATIONS

The overall messages of reconceptualising pain during PNE may be more important than any individual story or metaphor.

A Modern Pain Neuroscience Approach in Patients Undergoing Surgery for Lumbar Radiculopathy: A Clinical Perspective

Around 20% of patients undergoing surgery for lumbar radiculopathy develop chronic pain after surgery, leading to high socioeconomic burden. Current perioperative interventions, including education and rehabilitation, are not always effective in preventing prolonged or chronic postoperative pain and disability. Here, a shift in educational intervention from a biomedical towards a biopsychosocial approach for people scheduled for lumbar surgery is proposed. Pain neuroscience education (PNE) is a biopsychosocial approach that aims to decrease the threat value of pain by reconceptualizing pain and increasing the patient's knowledge about pain. This paper provides a clinical perspective for the provision of perioperative PNE, specifically developed for patients undergoing surgery for lumbar radiculopathy. Besides the general goals of PNE, perioperative PNE aims to prepare the patient for postsurgical pain and how to cope with it.

The experiences and beliefs of patients with complex regional pain syndrome: An exploratory survey study

Objectives To determine the beliefs and describe the health care experiences of patients with complex regional pain syndrome. Methods A survey tool for patients with complex regional pain syndrome was designed for this study. The survey tool collected self-reported measures associated with pain, disability, health care experiences, education, beliefs, and treatments. Results Thirty-one patients attending physical therapy for complex regional pain syndrome (mean age 40.48; female n = 20) completed the survey. Patients with presented with high levels of pain and disability and reported various changes associated with altered neuroplasticity such as confused body part recognition, left/right discrimination, neglect, and spreading pain. The patients' experiences with diagnostic testing and interventions are not in line with the current pain science research and/or evidence-based practice. Overall, patients are ill-informed, confused, and receive conflicting information. Discussion The suffering associated with complex regional pain syndrome is real, as told by patients. This suffering coincides with a lack of consensus by health care providers and conflicting information on complex regional pain syndrome. Overall, patient experiences show health care providers are not up to date with the current best-evidence regarding complex regional pain syndrome.

The clinical implementation of pain neuroscience education: A survey study

Pain neuroscience education (PNE) has gained considerable attention in research. Three systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. In the development of any new therapeutic approach, it is proposed that there are three stages: development, validation, and implementation. To date, the development and validation of PNE have been well-established. The third stage, implementation, however, lacks when it comes to PNE. The purpose of this study was to survey physical therapists (PT) on their experience and implementation of PNE, following a 15-hour PNE class. Upon development and validation of a PT-PNE survey, a random sample of PTs was invited to take the online survey. Two hundred and eighty-six PTs (female 56%) completed the PNE questionnaire. Ninety-one percent of PTs reported not being taught PNE in PT school. PT's are applying PNE into clinical practice to a variety of patients, experience outcomes in line with the current best-evidence, but struggle establishing which patients are ideal for PNE. The same five patient characteristics associated with success were also associated with failure, albeit in a different ranking order. This finding highlight the need to further investigate the factors associated with success and failure of PNE.

Three-year follow-up of a randomized controlled trial comparing preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy

BACKGROUND

Results from a previous multicenter randomized controlled trial (RCT) on preoperative pain neuroscience education (PNE) for lumbar radiculopathy found no significant difference in patient reported outcomes between groups. However, patients who received PNE viewed their surgical experience more favorably and utilized significantly less healthcare compared to those that did not. The purpose is to determine if the reduction in healthcare costs from 1-year would be continued at 3-year following surgery, and to explore differences (if any) in patient reported outcomes. Study design-analysis of 3-year follow-up data from RCT on preoperative PNE for lumbar radiculopathy.

METHODS

Participating patients from the previous RCT were contacted for 3-year follow-up. Of the 67 patients who commenced in the study, there were 61 who completed 1-year follow-up. Data packets were sent to these 61 patients to examine post-operative utilization of healthcare (Utilization of Healthcare Questionnaire); LBP [numeric rating scale (NRS)]; leg pain (NRS); function (Oswestry disability index); and beliefs and experiences related to LS (10 item survey with Likert responses).

RESULTS

At 3-year follow-up, 50 patients (29 females) responded, with 22 patients in the experimental group (EG) and 28 in the control group (CG). Cumulative medical expenses were 37% lower for the EG, with those patients spending less on X-rays and visits to their family physician, physical therapist, and massage therapist. There were no differences in patient reported outcomes between groups. Patients who received PNE continued to view their surgical experience more favorably compared to those that did not.

CONCLUSIONS

Adding a single PNE session prior to surgery for lumbar radiculopathy results in significant healthcare savings over 3 years. Educating such patients about normal responses to lumbar surgery (LS) in a neuroscience framework may result in lasting behavior changes following surgery.

Moving without moving: immediate management following lumbar spine surgery using a graded motor imagery approach: a case report

Representational body maps are dynamically maintained in the brain and negatively influenced by neglect, decreased movement and pain. Graded motor imagery (GMI) utilizing various tactile and cognitive processes has shown efficacy in decreasing pain, disability and movement restrictions in musculoskeletal pain. Limited information is known about the cortical changes patients undergo during lumbar surgery (LS), let alone the therapeutic effect of GMI for LS. A 56-year-old patient underwent LS for low back pain, leg pain and progressive neurological deficit. Twenty-four hours prior to and 48 h after LS various psychometric, physical movement and tactile acuity measurements were recorded. Apart from predictable postoperative increases in pain, fear-avoidance, disability and movement-restrictions, pressure pain thresholds (PPT), two-point discrimination (TPD) and tactile acuity was greatly reduced. The patient underwent six physiotherapy (PT) treatments receiving a GMI program aimed at restoring the PPT, TPD and tactile acuity. The results revealed that GMI techniques applied to a patient immediately after LS caused marked improvements in movement (flexion average improvement/session 3.3 cm; straight leg raise average 8.3°/session) and an immediate hypoalgesic effect. GMI may provide PT with a non-threatening therapeutic treatment for the acute LS patient and establish a new role for PT in acute LS patients.

The associations of illness perceptions and self-efficacy with psychological well-being of patients in preparation for joint replacement surgery

Patient well-being on referral to surgery likely affects their surgical experience yet few studies examine pre-surgical correlates of well-being. Guided by the Common Sense Model of Self-Regulation and Social Cognitive theory, this study examined whether illness and emotional representations, general and domain self-efficacy were associated with pre-surgical well-being. The pre-surgical assessment of a three-wave prospective study is reported. Fifty-four hip and knee replacements patients (mean age = 69.33; SD = 8.57) were recruited in the pre-surgery educational clinic at a UK general hospital. Patients completed a questionnaire-pack including the Revised Illness Perceptions Questionnaire, the General Self-Efficacy Scale, the Self-Efficacy for Rehabilitation Outcome Scale, the Falls-Efficacy Scale, and the Short Form of Psychological Well-Being Index. Multiple hierarchical regression analyses showed that above and beyond demographic and clinical characteristics, negative emotional representations were associated with lower psychological well-being while strong general self-efficacy beliefs were positively related to psychological well-being. Independent of demographic and clinical characteristics, joint replacement patients' psychological well-being was associated with their cognitions and emotional reactions to their condition before surgery. Early interventions could potentially target these modifiable factors to improve pre-surgical well-being in this group of patients, with potential for additional post-surgical benefit.

The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series

BACKGROUND

Recently a preoperative pain neuroscience education (NE) program was developed for lumbar surgery (LS) for radiculopathy as a means to decrease postoperative pain and disability. This study attempts to determine the short term effects, if any, of providing NE before surgery on patient outcomes.

METHODS

A case series of 10 patients (female = 7) received preoperative one-on-one educational session by a physical therapist on the neuroscience of pain, accompanied by an evidence-based booklet, prior to LS for radiculopathy. Post-intervention data was gathered immediately after NE, as well as 1, 3 and 6 months following LS. Primary outcome measures were Pain Catastrophization Scale (PCS), forward flexion, straight leg raise (SLR) and beliefs regarding LS.

RESULTS

Immediately following NE for LS for radiculopathy, all patients had lower PCS scores, with 5 patients exceeding the MDC score of 9.1 and 8 of the patients had PCS change scores exceeding the MDC by the 1, 3 and 6 month follow ups. Physical changes showed that fingertip-to-floor test in 6 patients had changes in beyond the MDC of 4.5 cm and 6 patients had changes in SLR beyond the MDC of 5.7°. The main finding, however, indicated a positive and more realistic shift in expectations regarding pain after the impending LS by all patients.

CONCLUSIONS

The results of the case series suggest that immediately after NE, patients scheduled for LS for radiculopathy had meaningful detectable changes in pain catastrophizing, fingertip-to-floor test, passive SLR and positive shifts in their beliefs about LS.

Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up

STUDY DESIGN

Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy.

OBJECTIVE

To determine if the addition of NE to usual preoperative education would result in superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery.

SUMMARY OF BACKGROUND DATA

One in 4 patients after lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is nonresponsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in populations with chronic low back pain.

METHODS

Eligible patients scheduled for LS for radiculopathy were randomized to receive either preoperative usual care (UC) or a combination of UC plus 1 session of NE delivered by a physical therapist (verbal one-on-one format) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and 1, 3, 6, and 12 months after LS: low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire).

RESULTS

At 1-year follow-up, there were no statistical differences between the experimental and control groups with regard to primary outcome measure of low back pain (P = 0.183), leg pain (P = 0.075), and function (P = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (P = 0.001); preoperative session preparing them for LS (P < 0.001) and LS meeting their expectations (P = 0.021). Health care utilization post-LS also favored the NE group (P = 0.007) resulting in 45% less health care expenditure compared with the control group in the 1-year follow-up period.

CONCLUSION

NE resulted in significant behavior change. Despite a similar pain and functional trajectory during the 1-year trial, patients with LS who received NE viewed their surgical experience more favorably and used less health care facility in the form of medical tests and treatments.

LEVEL OF EVIDENCE

2.