The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients

Experience of Student Nurse Anesthetists' Learning in the Operating Room During the COVID-19 Pandemic: A Qualitative Interview Study

PURPOSE

This study explores student nurse anesthetists' (SNAs) learning in the operating room during the coronavirus 2019 pandemic.

DESIGN

An explorative design with semistructured interviews was used.

METHODS

Thirteen former SNAs and 12 clinical supervisors (8 of whom were included in the final analysis) were recruited from 6 counties in Sweden. Participants were purposively recruited. Inclusion criterion for former SNAs was having completed the nurse anesthesia program in the fall of 2020 to spring 2022; and for nurse anesthetists, those who have experience in supervising SNAs. The interviews were analyzed with thematic analysis.

FINDINGS

The analysis identified one theme and five subthemes. The theme was that student learning was in focus despite an ongoing pandemic. Every learning situation contributed, and learning was triggered by the challenges. Both the SNAs and the supervisors exhibited resilience by accepting the situation and striving to do their absolute best in a nonoptimal learning environment. Over time, learning and supervision returned to normal.

CONCLUSIONS

During the pandemic, learning was ongoing despite stress, fear, and other challenging factors. Students' learning appears to have been prioritized. The study highlights that nurse anesthetists and SNAs were resilient, resourceful, and able to find new ways to keep learning going.

The impact of instrumented lumbar fusion surgery on psychiatric problems in elderly patients with degenerative spinal stenosis: The observational study

This is a prospective cohort study to investigate the effects of instrumented lumbar fusion surgery on psychiatric problems, including anxiety, insomnia, and depression, in patients with degenerative spinal stenosis, as well as on pain and the activities of daily living. Surgery was performed in the patients with Schizas grade C or D spinal stenosis with; if a patient's quality of life was impaired for at least 3 months or if patient had neurologic deficits. Finally, 69 patients were reviewed. Beck anxiety inventory, insomnia severity index, geriatric depression scale short form-Korean, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index was measured on the day surgery was decided on (T1), the day before surgery (T2), the day before discharge (T3), and 6 months after surgery (T4). The patients had mild degrees of anxiety, insomnia, and depression at T1, and Beck anxiety inventory, insomnia severity index, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index improved significantly by T4. In elderly patients with degenerative spinal stenosis, instrumented lumbar fusion surgery improves not only pain and activities of daily living, but also anxiety and insomnia. However, there was no improvement in depression over the 6-month follow-up period.

Preoperative Motor Function Associated with Short-Term Gain of Health-Related Quality of Life after Surgery for Lumbar Degenerative Disease: A Pilot Prospective Cohort Study in Japan

This study aimed to estimate the relationship between preoperative motor function and short-term recovery of health-related quality of life after lumbar surgery in patients with lumbar degenerative disease. This prospective cohort study involved 50 patients with lumbar degenerative disease at a general hospital in Japan. The primary outcome was the achievement of minimal clinically important difference (MCID) for EuroQOL 5 dimensions (EQ-5D) at discharge. Preoperative demographic, medication, surgical, and physical function data were collected. Logistic regression analysis was performed using the achievement of MCID for EQ-5D as the dependent variable and preoperative characteristics, including the Five Times Sit to Stand test (FTSTS), Oswestry Disability Index (ODI), and Self-rating Depression Scale (SDS), as the independent variables. The logistic regression analysis showed that Model 1 had a moderate predictive accuracy (Nagelkerke R2: 0.20; Hosmer-Lemeshow test: p = 0.19; predictive accuracy: 70.0%). Among the independent variables in the logistic regression model, the FTSTS was the only independent variable related to the achievement of MCID for EQ-5D at discharge (odds ratio: 0.03; 95% CI: 1.79 × 10-3, 0.18). Our results highlighted the importance of baseline motor function in the postoperative recovery of health-related quality of life in individuals with lumbar degenerative disease.

Understanding the Impact of Early Depressive Burden on Patient Perceptions of Outcomes Following Cervical Disc Replacement

OBJECTIVE

To evaluate the effect of early depressive burden on PROMs in the setting of cervical disc replacement (CDR).

METHODS

Patients who had undergone primary elective CDR with recorded preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9) scores were identified. Early depressive burden was calculated via addition of the preoperative and 6-week PHQ-9 scores. Patients were divided into 2 cohorts, those with summative PHQ-9 scores beneath one-half standard deviation less than the mean (Lesser Burden; LB) and those with summative PHQ-9 scores above one-half standard deviation greater than the mean (Greater Burden; GB). Magnitude of improvement in PROMs (ΔPROM) was compared within and between cohorts at 6-weeks (ΔPROM-6W) and final follow-up (ΔPROM-FF). PROMs evaluated included PROMIS-PF/NDI/VAS-Neck (VAS-N)/VAS-Arm (VAS-A)/PHQ-9.

RESULTS

Fifty-five patients were included with 34 in the LB cohort. The LB cohort demonstrated improvements from the preoperative baseline in 6-week PROMIS-PF/NDI/VAS-N/VAS-A (P ≤ 0.012, all). The GB cohort demonstrated improvements from the preoperative baseline in 6-week NDI/VAS-N/VAS-A/PHQ-9 (P ≤ 0.038, all). The GB cohort demonstrated greater ΔPROM-6W and ΔPROM-FF in PHQ-9 (P ≤ 0.047, both). The LB cohort demonstrated a greater ΔPROM-FF in PROMIS-PF (P = 0.023).

CONCLUSIONS

Patients with a greater depressive burden were more likely to experience greater magnitudes of improvements in PHQ-9 at both 6-week and final follow-up and experience clinically meaningful improvement in depressive symptoms. Patients with a lesser depressive burden were more likely to experience a greater magnitude of improvement in PROMIS-PF at final follow-up and experience clinically meaningful improvement in physical function.

Impact of Preoperative 12-item Short Form Mental Composite Scores on Clinical Outcomes in Cervical Disc Replacement

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We aim to examine the effects of preoperative mental health status on demographic, perioperative characteristics, and postoperative outcomes in patients undergoing cervical disc replacement (CDR).

SUMMARY OF BACKGROUND DATA

The effect of preoperative mental health status has not been widely studied in CDR.

METHODS

Patients undergoing primary CDR were retrospectively collected and stratified into 2 cohorts by 12-item Short Form Survey Mental Composite Score (SF-12 MCS) ≥48.9. Patients without preoperative SF-12 MCS scores or diagnosis of infection, malignancy, or trauma were excluded. Demographic information, perioperative characteristic, and patient reported outcome measures (PROMs) were collected. Patient reported outcome measurement information system physical function (PROMIS-PF)/SF-12 Physical Component Score (PCS)/SF-12 MCS/visual analog scale (VAS) neck/VAS leg/neck disability index (NDI) were collected preoperatively and 6 weeks/12 weeks/6 months/1 year postoperatively.

RESULTS

Eighty-seven patients were included, (47 having SF-12 MCS≥48.9). For PROMs, both cohorts had significant improvement from preoperative baseline, besides SF-12 PCS/MCS at 1 year for the depressed cohort and SF-12 MCS at all time points. The non-depressed cohort demonstrated significantly higher PROMIS-PF preoperatively and at 12 weeks, SF-12 PCS at 12 weeks, SF-12 MCS at all time points, decreased VAS neck at 12 weeks and NDI preoperatively and at 12 weeks, overall minimal clinically important difference (MCID) in most patients in all PROMs besides SF-12 MCS, and higher MCID for PROMIS-PF at 12 weeks. The depressed cohort demonstrated overall MCID in most patients with PROMIS-PF/SF-12 MCS/VAS neck/NDI, and a higher MCID for 6 weeks/12 weeks/6 months postoperatively and overall SF-12 PCS.

CONCLUSION

Whereas both cohorts demonstrated significantly improved PROMs from baseline, the non-depressed cohort demonstrated better physical function, mental health, decreased pain, and disability at various time points, whereas the depressed cohort demonstrated higher mental health MCID achievement at every time point except 1 year. These findings may be useful in managing expectations for patients undergoing cervical surgery.

Poor mental health scores correlate with inferior outcomes following minimally invasive transforaminal lumbar interbody fusion

BACKGROUND

Limited spine literature has studied the strength of association of mental health with other outcomes at time of survey collection. We aim to evaluate the degree to which mental health correlates with outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) at several postoperative periods.

METHODS

Patients having undergone elective MIS-TLIF were searched within a retrospective single-surgeon database. Five hundred eighty-five patients were included. Patient-reported outcomes (PROs) including Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), 12-item Short Form Physical Component Score (SF-12 PCS) and Mental Component Score (SF-12 MCS), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) back and leg pain, and Oswestry Disability Index (ODI) scores were collected preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year periods. Pearson's correlation tests were used to evaluate the association between both SF-12 MCS and PHQ-9 scores to other PROs at each period.

RESULTS

SF-12 MCS correlated with PROMIS PF (|r|= 0.308-0.531), SF-12 PCS (|r|= 0.207-0.328), VAS back (|r|= 0.279-0.474), VAS leg (|r|= 0.178-0.395), and ODI (|r|= 0.450-0.538) at all time points (P ≤ 0.021, all) except for preoperative SF-12 PCS and 1-year VAS leg. PHQ-9 correlated with PROMIS PF (|r|= 0.366-0.701), SF-12 PCS (|r|= 0.305-0.568), VAS back (|r|= 0.362-0.714), VAS leg (|r|= 0.319-0.694), and ODI (|r|= 0.613-0.784) at all periods (P < 0.001, all).

CONCLUSION

Poor mental health scores were correlated with lower physical function, elevated pain scores, and higher disability. PHQ-9 scores demonstrated stronger correlation in all relationships compared to SF-12 MCS. Optimization of patient mental health may lead to improved patient perception regarding function, pain, and disability following MIS-TLIF.

The prognostic value of fear-avoidance beliefs on postoperative pain and dysfunction for lumbar degenerative disk disease: a meta-analysis

The study aimed to explore the prognostic value of fear-avoidance beliefs (FABs) on postoperative pain and back-specific function for patients with lumbar degenerative disk disease (LDDD). FABs have been proven to be a predictorof pain and disability for patients with low back pain. However, whether FABs are a predictor of surgical outcomes for LDDD is a matter of debate. PubMed, Cochrane library, EMBASE, and EBSCO were searched for eligible cohort studies or secondary analyses of randomized controlled trials. Fixed-effect meta-analysis models were used to estimate odds ratios (OR) because of absent or low heterogeneity ( I ² < 50%). Subgroup analyses were conducted according to different follow-up durations. Forest plots were used for graphical representation. Six studies with a total of 829 participants were included in the meta-analyses. Risk of bias was high for three studies and moderate for the other three studies. For patients with LDDD, meta-analyses showed that FABs were a predictor of postoperative pain intensity [OR 2.88; 95% confidence interval (CI), 2.76-3.00] and back-specific function (OR 3.13; 95% CI, 3.02-3.24). Patients with FABs are less likely to report improvement in pain (OR 2.56; 95% CI, 1.73-3.86) and function (OR 2.81; 95% CI, 2.57-3.07). In conclusion, FABs were a predictor of postoperative pain and back-specific function for patients with LDDD. This prognostic value is sustained for a long period after surgery (>12 months). Clinicians are advised to initiate targeted interventions for patients with FABs at different stages after surgery. Due to the limited number and low quality of included studies, the results of this meta-analysis should be interpreted with caution.

Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF).

SUMMARY OF BACKGROUND DATA

Assessing postoperative inefficiencies is vital to increase the feasibility of ALF.

MATERIALS AND METHODS

Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge.

RESULTS

Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS.

CONCLUSIONS

Unavailability of PT, surgery after 1  pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge.

LEVEL OF EVIDENCE

4.

Health Literacy and Patient Participation in Shared Decision-Making in Orthopedic Surgery

The influence of health literacy on involvement in decision-making in orthopedic surgery has not been analyzed and could inform processes to engage patients. The goal of this study was to determine the relationship between health literacy and the patient's preferred involvement in decision-making. We conducted a cross-sectional observational study of patients presenting to a multispecialty orthopedic clinic. Patients completed the Literacy in Musculoskeletal Problems (LiMP) survey to evaluate their health literacy and the Control Preferences Scale (CPS) survey to evaluate their preferred level of involvement in decision-making. Statistical analysis was performed with Pearson's correlation and multivariable logistic regression. Thirty-seven percent of patients had limited health literacy (LiMP score <6). Forty-eight percent of patients preferred to share decision-making with their physician equally (CPS score=3), whereas 38% preferred to have a more active role in decision-making (CPS score≤2). There was no statistically significant correlation between health literacy and patient preference for involvement in decision-making (r=0.130; P=.150). Among patients with orthopedic conditions, there is no significant relationship between health literacy and preferred involvement in decision-making. Results from studies in other specialties that suggest that limited health literacy is associated with a preference for less involvement in decision-making are not generalizable to orthopedic surgery. Efforts to engage patients to be informed and participatory in decision-making through the use of decision aids and preference elicitation tools should be directed toward variation in preference for involvement in decision-making, but not toward patient health literacy. [Orthopedics. 2022;45(4):227-232.].

Dual Role of Neck Disability Index in the Assessment of Quality of Life in Cervical Spine Patients

INTRODUCTION

The Neck Disability Index (NDI) is a well-established measure for patients with cervical myelopathy, radiculopathy, or myeloradiculopathy. Few studies have examined the relationship between NDI and mental health outcomes after anterior cervical diskectomy and fusion (ACDF). Our study sets out to determine the possible correlations between NDI and mental health outcome measures after ACDF.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed for elective ACDF procedures from December 2013 to December 2019. Demographic and perioperative characteristics were collected. Primary outcomes of interest were NDI, 12-Item Short Form Mental Component Summary (SF-12 MCS), and Patient Health Questionnaire-9 (PHQ-9). Outcomes were collected preoperatively and postoperatively (6 weeks, 12 weeks, 6 months, 1 year, and 2 years). Postoperative improvement for all outcomes was evaluated using a paired Student t-test. Correlations between NDI and mental health outcomes were evaluated using the Pearson correlation coefficient. Strength of association was determined using the following criteria: weak (0.1 ≤ |r| < 0.3), moderate (0.3 ≤ |r| < 0.5), and strong (|r| ≥ 0.5).

RESULTS

A total of 225 patients were included in this study. Most of the patients underwent a single-level procedure and had a spinal pathology of herniated nucleus pulposus. NDI demonstrated significant improvements through 2 years compared with preoperative values (all P < 0.001). Similarly, SF-12 MCS and PHQ-9 significantly improved through 1-year postoperatively (all P ≤ 0.010) but was not maintained at 2 years (P = 0.835; P = 0.128). NDI demonstrated a significant but moderate correlation with SF-12 MCS at the preoperative time point, but a strong correlation was observed at all postoperative time points (all P ≤ 0.001). A significant and strong correlation between NDI and PHQ-9 was demonstrated at all time points (all P ≤ 0.002).

DISCUSSION

NDI demonstrated notable and strong correlations with mental health outcome measures at all postoperative time points. NDI is an effective measure to assess neck disability but may also help capture changes to mental health symptoms after ACDF.

A qualitative study with orthopaedic surgeons on pain catastrophizing and surgical outcomes: shifting from a medical towards a biopsychosocial model of surgery

BACKGROUND

Pain catastrophizing (PC) moderates surgical outcomes and behavioural interventions are recommended to optimise post-operative results. Less is known about surgeons' experiences of providing care and their attitudes towards the use of interventions in practice.

OBJECTIVE

It is therefore invaluable to understand surgeons' views on how best to support patients who may be at risk of suboptimal recovery. Eleven surgeons and three registrar orthopaedic practitioners took part in semi-structured interviews within a hospital setting. The surgical decision-making process, views of PC and the use of behavioural interventions in surgical practice were explored.

RESULTS

Thematic analysis identified five themes: pain expressions and pain behaviours affect the surgeons' decision-making process, when pathologies and symptoms do not match, psychological factors pertaining to unsatisfactory outcomes, a service gap in surgical care and the acceptability of using a screening tool in surgical practice to identify patients at risk of suboptimal recovery.

CONCLUSION

Orthopaedic surgeons face challenges in identifying who is likely to reach optimal versus suboptimal outcome. Surgeons are becoming increasingly aware of patient psychological distress being detrimental to outcomes, and they support the use of behavioural interventions to optimise post-operative outcomes or stop unnecessary treatments. The surgeons accept the use of a screening tool in surgical practice with better access to support services with input from allied health professionals. A screening tool may provide great utility for identifying at risk patients, to allow for modification of surgical patients care plans.

The Effect of the Severity of Preoperative Disability on Patient-Reported Outcomes and Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To compare patient-reported outcomes (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion stratified by preoperative disability.

METHODS

Minimally invasive transforaminal lumbar interbody fusions were grouped by preoperative Oswestry Disability Index (ODI) score: ODI <41 or ODI ≥41. PROMs administered pre/postoperatively included Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), visual analog scale (VAS) back/leg, ODI, and 12-Item Short-Form Physical Composite Score (SF-12 PCS)/12-Item Short-Form Mental Composite Score (SF-12 MCS). Satisfaction scores were collected for VAS back/leg and ODI. Coarsened exact match controlled for differences between cohorts. T tests compared mean PROMs and postoperative improvement/satisfaction between cohorts. Simple logistic regression compared MCID achievement.

RESULTS

After coarsened exact matching, there were 118 patients in the ODI ≤41 and 377 patients in the ODI >41 cohort. The ODI >41 cohort saw greater postoperative inpatient VAS pain score and narcotic consumption on days 0/1 (P < 0.018, all). PROMs differed between cohorts: PROMIS-PF, SF-12 PCS, ODI, VAS back/leg at all postoperative time points and SF-12 MCS at 6 weeks/12 weeks/6 months/1 year (P < 0.045, all). Patients in the ODI >41 cohort demonstrated greater proportion achieving MCID for ODI at all postoperative time points and for SF-12 MCS 6-week/12-week/6-month/1-year (P < 0.040, all). The ODI ≤41 cohort demonstrated greater MCID achievement for overall PROMIS-PF and SF-12 PCS 6 months (P < 0.047, all). Postoperative satisfaction was greater in the ODI ≤41 cohort for VAS leg 6 weeks/12 weeks, VAS back 6 weeks/12 weeks, and ODI all postoperative time points (P < 0.048, all).

CONCLUSIONS

Preoperative disability associated with worse postoperative PROMs and patient satisfaction for disability, back/leg pain at multiple time points. MCID achievement rates across cohorts were similar for most PROMs at most postoperative time points. Patients with severe disability may have unrealistic expectations for surgical benefits, influencing corresponding postoperative satisfaction.

Only two subscales of the Coping Strategies Questionnaire are culturally relevant for people with chronic low back pain in Nigerian Igbo populations: a cross-cultural adaptation and validation study

BACKGROUND

Pain coping strategies are important in the chronicity of low back pain and the associated disability. However, their exact influence is unknown in many African contexts such as rural Nigeria due to lack of outcome instruments with which to measure them. This study aimed to cross-culturally adapt and psychometrically test the Coping Strategies Questionnaire (CSQ) in Igbo populations in Nigeria.

METHODS

The CSQ was forward and back translated by clinical and non-clinical translators; evaluated by an expert review committee. The translated measure was piloted amongst twelve rural Nigerian dwellers with chronic low back pain (CLBP) using the think-aloud cognitive interviewing style. Internal consistency (Cronbach's alpha), test-retest reliability (intra-class correlation coefficient-ICC and Bland-Altman plot), and minimal detectable change were examined amongst 50 people with CLBP in rural and urban Nigerian populations. Construct validity was determined by assessing the correlations between the adapted CSQ and measures of disability, pain intensity, fear avoidance beliefs, and illness perceptions using Spearman's correlation analyses with 200 adults with CLBP in rural Nigeria. Exploratory factor analyses using Kaiser criterion (eigenvalue) and parallel analysis as methods for determining dimensionality were conducted with the same sample.

RESULTS

Fourteen out of 42 items were routinely adopted in this population including all items of catastrophising subscale, and all but one item of praying and hoping subscale. Catastrophising and praying and hoping subscales had the highest Cronbach's alpha. All subscales had high ICCs with Bland-Altman plots that showed good agreement. All coping strategies were positively correlated with self-reported disability and pain intensity with catastrophising subscale having the highest values. Seven-factor and three-factor structures were produced with the Kaiser criterion and parallel analysis, with different items from the original CSQ, except for catastrophising.

CONCLUSIONS

Catastrophising and praying and hoping may be the relevant coping strategies in this population. More culturally relevant measures of pain coping strategies that include adaptive coping strategies may need to be developed for African contexts such as rural Nigeria.

Preoperative Neck Disability Severity Limits Extent of Postoperative Improvement Following Cervical Spine Procedures

Objective

Our study aims to evaluate the impact of severity of preoperative Neck Disability Index (NDI) on postoperative patient-reported outcome measures (PROMs).

Methods

A retrospective review of primary, elective, single or multilevel anterior cervical discectomy and fusion or cervical disc arthroplasty procedures between 2013 and 2019 was performed. Visual analogue scale (VAS) neck and arm, NDI, 12-item Short Form physical and mental composite score (SF-12 PCS and MCS), Patient-Reported Outcome Measurement Information System physical function, and 9-item Patient Health Questionnaire (PHQ-9) were collected preoperatively and postoperatively. Patients were categorized by preoperative NDI: none-to-mild disability (< 30); moderate disability (≥ 30 to < 50); severe disability (≥ 50 to < 70); complete disability (≥ 70). The impact of preoperative NDI on PROM scores and minimum clinically important difference (MCID) achievement rates were evaluated.

Results

The cohort included 74 patients with none-to-mild disability, 95 moderate, 76 severe, and 17 with complete disability. Patients with greater preoperative disability demonstrated significantly different scores for NDI, VAS neck, SF-12 MCS, and PHQ-9 at all timepoints (p < 0.001). Patients with more severe disability demonstrated different magnitudes of improvement for NDI (all p < 0.001), VAS neck (p ≤ 0.009), VAS arm (p = 0.025), and PHQ-9 (p ≤ 0.011). The effect of preoperative severity on MCID achievement was demonstrated for NDI and for PHQ-9 (p ≤ 0.007).

Conclusion

Patients with severe neck disability demonstrated differences in pain, disability, physical and mental health. MCID achievement also differed by preoperative symptoms severity. Patients with more severe neck disability may be limited to the degree of improvement in quality of life but perceive them as significant changes.

Combined Depression and Anxiety Influence Patient-Reported Outcomes after Lumbar Fusion

BACKGROUND

Currently, no studies have assessed what effect the presence of both anxiety and depression may have on patient-reported outcome measurements (PROMs) compared to patients with a single or no mental health diagnosis.

METHODS

Patients undergoing 1- to 3-level lumbar fusion at a single academic hospital were retrospectively queried. Anyone with depression and/or anxiety was identified using an existing clinical diagnosis in the medical chart. Patients were separated into 3 groups: no depression or anxiety (NDA), depression or anxiety alone (DOA), and combined depression and anxiety (DAA). Absolute PROMs, recovery ratios, and the percentage of patients achieving minimal clinically important difference (% MCID) between groups were compared using univariate and multivariate analysis.

RESULTS

Of the 391 patients included in the cohort, 323 (82.6%) were in the NDA group, 37 (9.5%) in the DOA group, and 31 (7.9%) in the DAA group. Patients in the DAA group had significantly worse outcome scores before and after surgery with respect to Short Form-12 mental component score (MCS-12) and Oswestry Disability Index (ODI) scores (P <.001); however, the change in PROMs, recovery ratio, % MCID were not found to be significantly different between groups. Using multivariate analysis, the DAA group was found to be an independent predictor of worse improvement in MCS-12 and ODI scores (P = .026 and P = .001, respectively).

CONCLUSIONS

Patients with combined anxiety and depression fared worse with respect to disability before and after surgery compared to patients with a single diagnosis or no mental health diagnosis; however, there were no significant differences in recovery ratio or % MCID.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Combined anxiety and depression may predict less improvement in MCS-12 and ODI after lumbar arthrodesis compared with single or no mental health diagnosis.

Psychosocial Mechanisms of Cognitive-Behavioral-Based Physical Therapy Outcomes After Spine Surgery: Preliminary Findings From Mediation Analyses

OBJECTIVE

Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery.

METHODS

In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months.

RESULTS

Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1]).

CONCLUSIONS

This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism.

IMPACT

Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs.

Support for a Three-Item Questionnaire Prior to Spinal Surgery: A Health-Related Quality of Life Outcome Study

Objective  Elective lumbar and cervical operations are becoming more common in the United States. Additionally, there is a movement in the literature and clinical practice to discover short versions of longer measures as a way to anticipate an outcome. This study aims to provide neurosurgeons in practice with a three-item questionnaire that can guide referrals to psychological services presurgery. Ultimately, results could lead to an improvement in health-related quality of life (HRQoL) postspinal surgery.

Methods  This quantitative-descriptive, survey-based design with a retrospective chart review component followed 47 patients at baseline ( N = 47), 3 months ( N = 20), 6 months ( N = 31), and 1 year ( N = 19). A single item from the Coping Strategies Questionnaire, the Survey of Pain Attitudes, and the Tampa Scale of Kinesiophobia were utilized in the three-item questionnaire as a baseline measure. Patient-Reported Outcomes Measurement Information System Global Health measured HRQoL outcome at all time points. A linear regression model was conducted to predict mental health QoL postspinal surgery.

Results  This measure can predict mental health QoL outcomes up to 3-month postsurgery. Six-month and 1-year follow-ups are statistically inconclusive.

Conclusion  Individuals who are undergoing spinal surgery show lower mental health QoL outcome at baseline and 3-month postsurgery when responses on a three-item questionnaire are elevated. Limitations and future directions are discussed.

The impact of self-efficacy and health literacy on outcome after bariatric surgery in Sweden: a protocol for a prospective, longitudinal mixed-methods study

INTRODUCTION

A person-centred approach, to know about a person's individual weaknesses and strengths, is warranted in today's healthcare in Sweden. When a person suffers from obesity, there are not only risks for comorbidities but also increased risk for decreased health-related quality of life (HRQoL). After bariatric surgery, there are also risks for complications; however, healthcare service expects the person to have sufficient ability to handle recovery after surgery. The need is to investigate how a person's self-efficacy and health literacy(HL) skills are important to determine their effect on recovery as well as HRQoL after bariatric surgery. It can, involve the person in the care, improve shared decision-making, and perhaps decrease complications and readmissions.

METHOD AND ANALYSIS

This is a prospective, longitudinal mixed-methods study with the intent of including 700 patients from three bariatric centres in Sweden (phase 1); 20 patients will be included in a qualitative study (phase 2). Inclusion criteria will be age >17 years, scheduled primary bariatric surgery and ability to read and understand the Swedish language in speech and in writing. Inclusion criteria for the qualitative study will be patients who reported a low self-efficacy, with a selection to ensure maximum variation regarding age and gender. Before bariatric surgery patients will answer a questionnaire including 20 items. Valid and reliable instruments will be used to investigate general self-efficacy (10 items) and functional and communicative and critical HL (10 items). This data collection will then be merged with data from the Scandinavian Obesity Surgery Registry. Analysis will be performed 30 days, 1 year and 2 years after bariatric surgery. One year after bariatric surgery the qualitative study will be performed. The main outcomes are the impact of a person's self-efficacy and HL on recovery after bariatric surgery.

ETHICS AND DISSEMINATION

The study has received approval from the ethical review board in Uppsala, Sweden (number 2018/256). The study results will be disseminated through peer-reviewed publications and conference presentations to the scientific community and social media.

Predicting clinical outcome and length of sick leave after surgery for lumbar spinal stenosis in Sweden: a multi-register evaluation

PURPOSE

Lumbar spinal stenosis (LSS) can be surgically treated, with variable outcome. Studies have linked socioeconomic factors to outcome, but no nation-wide studies have been performed. This register-based study, including all patients surgically treated for LSS during 2008-2012 in Sweden, aimed to determine predictive factors for the outcome of surgery.

METHODS

Clinical and socioeconomic factors with impact on outcome in LSS surgery were identified in several high-coverage registers, e.g., the national quality registry for spine surgery (Swespine, FU-rate 70-90%). Multivariate regression analyses were conducted to assess their effect on outcome. Two patient-reported outcome measures, Global Assessment of leg pain (GA) and the Oswestry Disability Index (ODI), as well as length of sick leave after surgery were analyzed.

RESULTS

Clinical and socioeconomic factors significantly affected health outcome (both GA and ODI). Some predictors of a good outcome (ODI) were: being born in the EU, reporting no back pain at baseline, a high disposable income and a high educational level. Some factors predicting a worse outcome were previous surgery, having had back pain more than 2 years, having comorbidities, being a smoker, being on social welfare and being unemployed.

CONCLUSIONS

The study highlights the relevance of adding socioeconomic factors to clinical factors for analysis of patient-reported outcomes, although the causal pathway of most predictors' impact is unknown. These findings should be further investigated in the perspective of treatment selection for individual LSS patients. The study also presents a foundation of case mix algorithms for predicting outcome of surgery for LSS. These slides can be retrieved under Electronic Supplementary Material.

Patients with severe low back pain exhibit a low level of physical activity before lumbar fusion surgery: a cross-sectional study

BACKGROUND

People with severe low back pain are at higher risk of poor health. Patients scheduled for lumbar fusion surgery are assumed to have low levels of physical activity, but few data exist. The aim of the study was firstly to investigate preoperative levels of objectively measured physical activity in patients with severe low back pain waiting for lumbar fusion surgery, and secondly to investigate whether factors in the fear-avoidance model were associated with these levels.

METHODS

We included 118 patients waiting for lumbar fusion surgery (63 women and 55 men; mean age 46 years). Physical activity expressed as steps per day and total time spent in at least moderate-intensity physical activity was assessed with ActiGraph GT3X+ accelerometers. The data were compared to the WHO recommendations on physical activity for health. Whether factors in the fear-avoidance model were associated with physical activity was evaluated by two different multiple linear regression models.

RESULTS

Ninety-six patients (83%) did not reach the WHO recommendations on physical activity for health, and 19 (16%) patients took fewer than 5000 steps per day, which indicates a sedentary lifestyle. On a group level, higher scores for fear of movement and disability were associated with lower numbers of steps per day.

CONCLUSION

A high proportion of the patients did not reach the WHO recommendations on physical activity and are therefore at risk of poor health due to insufficient physical activity. We also found a negative association between both fear of movement and disability, and the number of steps per day. Action needs to be taken to motivate patients to be more physically active before surgery, to improve health postoperatively. There is a need for interventions aimed at increasing physical activity levels and reducing barriers to physical activity in the prehabilitation phase of this patient group.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN 17115599 , retrospectively Registered 18 may 2015.

Anxiety and depression in spine surgery-a systematic integrative review

BACKGROUND

Symptoms of preoperative anxiety and depression occur in approximately one-third of patients with chronic back pain undergoing surgery. In the last 2 decades, several studies have established that preoperative anxiety and depression are important outcome predictors of greater pain and physical impairments, and lower health-related quality of life in patients undergoing spine surgery. To accommodate symptoms of anxiety and depression and thereby better surgical outcomes, we need to identify factors associated with these symptoms.

PURPOSE

We aimed to identify factors associated with symptoms of anxiety and depression in adults both before and after undergoing spinal surgery.

STUDY DESIGN

An integrative literature review was carried out.

METHODS

The independent charity Helsefonden supported this literature review by contributing $45,000 to remunerate a dedicated investigator. A systematic literature search was conducted in PubMed, CINAHL, PsycINFO, Embase, Scopus, Cochrane, and Web of Science. A three-step selection and assessment process was conducted; titles and abstracts of 1,124 articles were skimmed for relevance and of these, 53 articles were found to be of relevance and were read in full. Articles not meeting the inclusion criteria (n=26) were excluded. The 31 articles were critically appraised for methodological validity; 14 of these were synthesized and analyzed using a convergent qualitative design to transform both qualitative and quantitative articles into qualitative findings.

RESULTS

Fourteen studies were included, reporting results based on 4,833 participants, 3,017 men and 1,816 women, whose mean age was approximately 49 years. From these results, we extracted 75 individual findings, which we then divided into five categories of factors associated with anxiety and depression both before and after undergoing spine surgery: pain, information, disability, employment, and mental health.

CONCLUSIONS

Five categories of interacting factors that influenced symptoms of anxiety and depression both before and after surgery were identified: pain, lack of information, disability, return to work, and mental health. Information appears to have a regulating effect on anxiety and depression.

Preoperative Leg Pain Score Predicts Patient Satisfaction After Transforaminal Lumbar Interbody Fusion Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aims to determine the preoperative predictors of postoperative satisfaction in transforaminal lumbar interbody fusion (TLIF) surgery in order to improve management of patient groups at high risk of dissatisfaction. We retrospectively reviewed prospectively collected data on patients who underwent open TLIF in a tertiary hospital between 2008 and 2012 with 2-year follow-up and performed multivariate analysis for their preoperative variables.

METHODS

A multivariate regression analysis was performed for the 217 patients to identify preoperative predictors of postoperative satisfaction. Clinical outcomes were evaluated using Oswestry Disability Index (ODI), North American Spine Society (NASS) Neurogenic Symptom Score (NSS), 36-item Short-Form Survey (SF-36; mean Physical and Mental Health scores), numerical pain rating scale (NPRS) for pain, and NASS Questionnaire.

RESULTS

Significant improvements were seen in the postoperative ODI, NSS, SF-36, and NPRS scores at 2 years (P < .05). Eighty-six percent of the patients had their expectations of surgery met, and 94.7% of the patients were satisfied with the results of treatment at 2 years. From the multivariate regression model, patients with higher preoperative NPRS pain score (odds ratio = 1.323; 95% confidence interval = 1.071-1.633; P = .009) was more likely to be satisfied at 2 years.

CONCLUSIONS

TLIF surgery provided significant health-related quality-of-life scores and symptom improvement in terms of SF-36, ODI, NSS, and NPRS, with a high proportion of patients being satisfied with the results of surgery. Patients with higher preoperative NPRS leg pain were more likely to be satisfied at 2 years. Patient-reported satisfaction may be largely influenced by the improvement of radicular leg pain.

Interdisciplinary Cognitive-Behavioral Therapy as Part of Lumbar Spinal Fusion Surgery Rehabilitation: Experience of Patients With Chronic Low Back Pain

Supplemental Digital Content is Available in the Text.

BACKGROUND:

Patients receiving lumbar spinal fusion surgery often have persisting postoperative pain negatively affecting their daily life. These patients may be helped by interdisciplinary cognitive-behavioral therapy which is recognized as an effective intervention for improving beneficial pain coping behavior, thereby facilitating the rehabilitation process of patients with chronic pain.

PURPOSE:

The purpose of this study was to describe the lived experience of patients recovering from lumbar spinal fusion surgery and to explore potential similarities and disparities in pain coping behavior between receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy.

METHODS:

We conducted semistructured interviews with 10 patients; 5 receiving cognitive-behavioral therapy in connection with their lumbar spinal fusion surgery and 5 receiving usual care. We conducted a phenomenological analysis to reach our first aim and then conducted a comparative content analysis to reach our second aim.

RESULTS:

Patients' postoperative experience was characterized by the need to adapt to the limitations imposed by back discomfort (coexisting with the back), need for recognition and support from others regarding their pain, a relatively long rehabilitation period during which they “awaited the result of surgery”, and ambivalence toward analgesics. The patients in both groups had similar negative perception of analgesics and tended to abstain from them to avoid addiction. Coping behavior apparently differed among receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. Receivers prevented or minimized pain by resting before pain onset, whereas nonreceivers awaited pain onset before resting.

CONCLUSION:

The postoperative experience entailed ambivalence, causing uncertainty, worry and insecurity. This ambivalence was relieved when others recognized the patient's pain and offered support. Cognitive-behavioral therapy as part of rehabilitation may have encouraged beneficial pain coping behavior by altering patients' pain perception and coping behavior, thereby reducing adverse effects of pain.

Pre-optimization of spinal surgery patients: Development of a neurosurgical enhanced recovery after surgery (ERAS) protocol

OBJECTIVE

Despite surgical, technological, medical, and anesthetic improvements, patient outcomes following elective neurosurgical procedures can be associated with high morbidity. Enhanced recovery after surgery (ERAS) protocols are multimodal care pathways designed to optimize patient outcomes by addressing pre-, peri-, and post-operative factors. Despite significant data suggesting improved patient outcomes with the adoption of these pathways, development and implementation has been limited in the neurosurgical population.

METHODS/RESULTS

This study protocol was designed to establish the feasibility of a randomized controlled trial to assess the efficacy of implementation of an ERAS protocol on the improvement of clinical and patient reported outcomes and patient satisfaction scores in an elective inpatient spine surgery population. Neurosurgical patients undergoing spinal surgery will be recruited and randomly allocated to one of two treatment arms: ERAS protocol (experimental group) or hospital standard (control group). The experimental group will undergo interventions at the pre-, peri-, and post-operative time points, which are exclusive to this group as compared to the hospital standard group.

CONCLUSIONS

The present proposal aims to provide supporting data for the application of these specific ERAS components in the spine surgery population and provide rationale/justification of this type of care pathway. This study will help inform the design of a future multi-institutional, randomized controlled trial.

RESULTS

of this study will guide further efforts to limit post-operative morbidity in patients undergoing elective spinal surgery and to highlight the impact of ERAS care pathways in improving patient reported outcomes and satisfaction.

Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery

OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

Age-based disparities in the use of total thyroidectomy for papillary thyroid carcinoma

BACKGROUND

Elderly patients may be less likely than younger patients to receive indicated therapy. We hypothesized that older patients with papillary thyroid carcinoma (PTC) would be less likely to receive total thyroidectomy (TT) than their younger counterparts.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results database were queried for adult patients diagnosed with PTC from 2000 through 2009. Patients were categorized according to whether they received a TT or less than a total thyroidectomy (<TT). We used multivariate logistic regression to predict the use of <TT. The likelihood of undergoing <TT was reported as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Of the 67,961 patients identified with PTC, 51,276 (75%) received TT, 14,750 (22%) <TT and 1935 (3%) no surgery. On multivariate analysis, advancing age increased the likelihood of receiving <TT (age 45-54 OR 1.15, CI [1.09-1.20]; age 55-64 OR 1.20, CI [1.14-1.26]; age 65-74 OR 1.40, CI [1.32-1.49]; 75-84 OR 1.80, CI [1.65-1.95]; ≥85 OR 3.01, CI [2.51-3.62], all p < 0.001).

CONCLUSIONS

Older patients with PTC are less likely to receive TT. Further research is needed to assess if older patients are negatively impacted by less complete surgery.

The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review

OBJECTIVE The purpose of this study was to provide a systematic and comprehensive review of the existing literature regarding postfusion rehabilitation. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors conducted an exhaustive review of multiple electronic databases. Potential articles were screened using inclusion/exclusion criteria. Two authors independently analyzed these studies using predefined data fields, including study quality indicators such as level of evidence and availability of accepted patient-reported outcomes measures. These findings were synthesized in a narrative format. A third author resolved disagreements regarding the inclusion of a study. RESULTS Twenty-one articles with I or II levels of evidence were included in the review. The authors divided the findings of the literature review into several groups: rehabilitation terminology, timing and duration of postfusion rehabilitation, the need for rehabilitation relative to surgery-related morbidity, rehabilitation's relationship to outcomes, and cognitive and psychosocial aspects of postsurgical rehabilitation. Current evidence generally supports formal rehabilitation after lumbar fusion surgery. Starting physical therapy at the 12-week postoperative mark results in better outcomes at lower cost than an earlier, 6-week start. Where available, psychosocial support improves outcomes. However, a number of the questions could not be answered with high-grade evidence. In these cases, the authors used "best evidence available" to make recommendations. There are many cases in which different types of caregivers use clinical terminology differently. The data supporting an optimal protocol for postfusion rehabilitation remains elusive but, using the data available, the authors have crafted recommendations and a model protocol, which is currently undergoing prospective study. CONCLUSIONS Rehabilitation has long been a common feature in the postoperative management of patients undergoing spinal fusion. Although caregivers from multiple disciplines agree that the majority of their patients will benefit from this effort, the supporting data remain sparse. In creating a model protocol for postlumbar fusion rehabilitation, the authors hope to share a starting point for future postoperative lumbar fusion rehabilitation research.

What factors are predictors of emotional health in patients with full-thickness rotator cuff tears?

BACKGROUND

The importance of emotional and psychological factors in treatment of patients with rotator cuff disease has been recently emphasized. Our goal was to establish factors most predictive of poor emotional health in patients with full-thickness rotator cuff tears (FTRCTs).

METHODS

In 2007, we began to prospectively collect data on patients with symptomatic, atraumatic FTRCTs. All patients completed a questionnaire collecting data on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcomes (12-Item Short Form Health Survey, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff Index [WORC], Single Assessment Numeric Evaluation score, Shoulder Activity Scale). Physicians recorded physical examination and imaging data. To evaluate the predictors of lower WORC emotion scores, a linear multiple regression model was fit.

RESULTS

Baseline data for 452 patients were used for analysis. In patients with symptomatic FTRCTs, the factors most predictive of worse WORC emotion scores were higher levels of pain (interquartile range odds ratio, -18.9; 95% confidence interval, -20.2 to -11.6; P < .0001) and lower Single Assessment Numeric Evaluation scores (rating of percentage normal that patients perceive their shoulder to be; interquartile range odds ratio, 6.2; 95% confidence interval, 2.5-9.95; P = .0012). Higher education (P = .006) and unemployment status (P = .0025) were associated with higher WORC emotion scores.

CONCLUSIONS

Education level, employment status, pain levels, and patient perception of percentage of shoulder normalcy were most predictive of emotional health in patients with FTRCTs. Structural data, such astendon tear size, were not. Those with poor emotional health may perceive their shoulder to be worse than others and experience more pain. This may allow us to better optimize patient outcomes with nonoperative and operative treatment of rotator cuff tears.

Evaluating rehabilitation following lumbar fusion surgery (REFS): study protocol for a randomised controlled trial

Background

The rate of lumbar fusion surgery (LFS) is increasing. Clinical recovery often lags technical outcome. Approximately 40 % of patients undergoing LFS rate themselves as symptomatically unchanged or worse following surgery. There is little research describing rehabilitation following LFS with no clear consensus as to what constitutes the optimum strategy. It is important to develop appropriate rehabilitation strategies to help patients manage pain and recover lost function following LFS.

Methods/design

The study design is a randomised controlled feasibility trial exploring the feasibility of providing a complex multi-method rehabilitation intervention 3 months following LFS. The rehabilitation protocol that we have developed involves small participant groups of therapist led structured education utilising principles of cognitive behavioral therapy (CBT), progressive, individualised exercise and peer support. Participants will be randomly allocated to either usual care (UC) or the rehabilitation group (RG). We will recruit 50 subjects, planning to undergo LFS, over 30 months. Following LFS all participants will experience normal care for the first 3 months. Subsequent to a satisfactory 3 month surgical review they will commence their allocated post-operative treatment (RG or UC). Data collection will occur at baseline (pre-operatively), 3, 6 and 12 months post-operatively. Primary outcomes will include an assessment of feasibility factors (including recruitment and compliance). Secondary outcomes will evaluate the acceptability and characteristics of a limited cluster of quantitative measures including the Oswestry Disability Index (ODI) and an aggregated assessment of physical function (walking 50 yards, ascend/descend a flight of stairs). A nested qualitative study will evaluate participants’ experiences.

Discussion

This study will evaluate the feasibility of providing complex, structured rehabilitation in small groups 3 months following technically successful LFS. We will identify strengths and weakness of the proposed protocol and the usefulness and characteristics of the planned outcome measures. This will help shape the development of rehabilitation strategies and inform future work aimed at evaluating clinical efficacy.

Trial registration

ISRCTN60891364, 10/07/2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0751-9) contains supplementary material, which is available to authorized users.

The relationships of self-efficacy, physical activity, and paid work to health-related quality of life among patients with chronic obstructive pulmonary disease (COPD)

Purpose

Although chronic obstructive pulmonary disease (COPD) primarily affects the lungs, it is regarded as a systemic disorder associated with comorbidity and physical deterioration, which often results in reduced levels of health-related quality of life (HRQoL). Self-efficacy is an important concept in self-management, which is vital for improving HRQoL in patients with COPD. The purpose of this study was to examine how general self-efficacy, leisure time physical activity, and sociodemographic variables such as employment status are related to the physical and mental health components of HRQoL in patients with COPD.

Patients and methods

In this cross-sectional study, 97 COPD patients (54.6% male, mean age 64.6 years, standard deviation [SD] 9.5) beginning a pulmonary rehabilitation program completed three self-report questionnaires: the short form (SF)-12v2 Health Survey as a measure of HRQoL; the General Self-Efficacy Scale; and a standardized instrument measuring regular leisure time physical activity.

Results

The physical health component median score was 31.3 (interquartile range [IQR] 16.3) and the mental health component median score was 45.9 (IQR 21.5). Two sets of linear regression analyses were performed, one predicting physical health and the other predicting mental health. The first analysis showed that better physical health was directly related to being in paid work (P-value <0.001), but was not significantly related to age, sex, marital status, education, work status, physical activity, or self-efficacy. In the second analysis, better mental health was directly related to living with a partner, being physically active, and having higher self-efficacy (P-value <0.001).

Conclusion

The findings suggest that general self-efficacy has differential relationships to the two dimensions of HRQoL. Our results indicate that general self-efficacy, physical activity, and paid work might be important factors for improving HRQoL of persons with COPD, and should be taken into consideration in pulmonary rehabilitation.

Early postoperative fear of movement predicts pain, disability, and physical health six months after spinal surgery for degenerative conditions

BACKGROUND CONTEXT

The fear-avoidance model offers a promising framework for understanding the development of chronic postoperative pain and disability. However, limited research has examined this model in patients undergoing spinal surgery.

PURPOSE

To determine whether preoperative and early postoperative fear of movement predicts pain, disability, and physical health at 6 months following spinal surgery for degenerative conditions, after controlling for depressive symptoms and other potential confounding variables.

STUDY DESIGN/SETTING

A prospective cohort study conducted at an academic outpatient clinic.

PATIENT SAMPLE

One hundred forty-one patients undergoing surgery for lumbar or cervical degenerative conditions.

OUTCOME MEASURES

Self-reported pain and disability were measured with the Brief Pain Inventory and the Oswestry Disability Index/Neck Disability Index, respectively. The physical composite scale of the 12-Item Short-Form Health Survey (SF-12) measured physical health.

METHODS

Data collection occurred preoperatively and at 6 weeks and 6 months following surgery. Fear of movement was measured with the Tampa Scale for Kinesiophobia and depression with the Prime-MD PHQ-9.

RESULTS

One hundred and twenty patients (85% follow-up) completed the 6-month postoperative assessment. Multivariable mixed-method linear regression analyses found that early postoperative fear of movement (6 weeks) predicted pain intensity, pain interference, disability, and physical health at 6-month follow-up (p<.05). Preoperative and early postoperative depression predicted pain interference, disability, and physical health.

CONCLUSION

Results provide support for the fear-avoidance model in a postsurgical spine population. Early postoperative screening for fear of movement and depressive symptoms that do not acutely improve following surgical intervention appears warranted. Cognitive and behavioral strategies may be beneficial for postsurgical patients with high fear of movement and/or depressive symptoms.

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

Background

We sought to determine current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy.

Methods

An online cross-sectional survey was used to study a random sample of spine surgeons in the United States. The Spinal Surgery Education Questionnaire (SSEQ) was developed based on previous related surveys and assessed for face and content validity by an expert panel. The SSEQ captured information on demographics, content, delivery methods, utilization, and importance of preoperative education as rated by surgeons. Descriptive statistics were used to describe the current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy.

Results

Of 200 surgeons, 89 (45% response rate) responded to the online survey. The majority (64.2%) provide preoperative education informally during the course of clinical consultation versus a formal preoperative education session. The mean time from the decision to undergo surgery to the date of surgery was 33.65 days. The highest rated educational topics are surgical procedure (96.3%), complications (96.3%), outcomes/expectations (93.8%), anatomy (92.6%), amount of postoperative pain expected (90.1%), and hospital stay (90.1%). Surgeons estimated spending approximately 20% of the preoperative education time specifically addressing pain. Seventy-five percent of the surgeons personally provide the education, and nearly all surgeons (96.3%) use verbal communication with the use of a spine model.

Conclusions

Spine surgeons believe that preoperative education is important and use a predominantly biomedical approach in preparing patients for surgery. Larger studies are needed to validate these findings.

The Relationship between Beliefs about Pain and Functioning with Rheumatologic Conditions

Pain beliefs influence understanding of pain mechanisms and outcomes. This study in rheumatologic conditions sought to determine a relationship between beliefs about pain and functioning. Participants in Arthritis New Zealand's (ANZ) exercise and education programmes were used. Demographic data and validated instruments used included the Arthritis Impact Measurement Scale 2nd version-Short Form (AIMS2-SF) to measure functioning, and two scales of organic and psychological beliefs in Pain Beliefs Questionnaires (PBQ) to measure pain beliefs. 236 Members of ANZ were surveyed anonymously with AIMS2-SF and PBQ, with a 61% response rate; 144 responses were entered into the database. This study used α of 0.05 and a 1-β of 0.8 to detect for significant effect size estimated to be r = 0.25. Analysis revealed a significant relationship between organic beliefs scale of PBQ and functioning of AIMS2-SF, with an r value of 0.32 and P value of 0.00008. No relationship was found between psychological beliefs scale of PBQ and AIMS2-SF. Organic pain beliefs are associated with poorer functioning. Psychological pain beliefs are not. Beliefs might have been modified by ANZ programmes. Clinicians should address organic pain beliefs early in consultation. Causal links between organic pain beliefs and functioning should be clarified.

A diagnostic classification for lumbar spine registry development

BACKGROUND CONTEXT

Low back pain (LBP) is a symptom, not a diagnosis. The failure to differentiate underlying diagnoses in patients complaining of LBP is one of the primary reasons that studies examining treatments for LBP have yielded inconsistent results. To design a lumbar spine registry such that the accumulated data provide applicable guidance for clinical treatment, the incorporation of a functional diagnostic matrix is critical.

PURPOSE

To propose a clinically relevant diagnostic classification scheme, simple enough for use in clinical practice but granular enough to differentiate characteristics that impact clinical outcome.

STUDY DESIGN

Case-based development, feasibility, and reliability testing of a classification scheme.

PATIENT SAMPLE

Thirty case histories were compiled. Each case consisted of a brief clinical history with physical examination findings as well as pertinent radiographic images, including computed tomography scan and magnetic resonance image when available.

OUTCOME MEASURES

Kappa values for inter- and intrarater reliability.

METHODS

Thirty-six physicians were asked to provide a three-digit diagnostic code, specifying Symptoms, Structural Pathology, and Compressive Pathology for each case. The cases were then randomly rearranged and sent back to the physicians 2 weeks later for a second review. Inter- and intraobserver reliability was calculated using Randolph's free-marginal multirater kappa. Symptoms are classified differentiating between patients with back or leg pain dominance and those with equal back and leg pain; symptoms are also divided as acute versus chronic. Additional categories denote neurogenic claudication and cauda equina. Structural Pathology includes an option for age appropriate changes. Additional options include disc pathology with and without disc space collapse; spondylolisthesis or spondylolysis without olisthesis; and regional spinal deformity, either scoliosis or kyphosis. The remaining structural categories are primary facet pathology and nonunion after attempted fusion. Compressive Pathology includes a category indicating the absence of any study on which to judge compressive pathology and a category indicating an available study, but the lack of any clinically relevant compressive pathology. Additional options are for either central compression or lateral recess/foraminal/extraforaminal compressive pathology of any etiology. There is also a category for combined central and lateral compression. The final category is recurrent compression, central, lateral, or combined compression after surgical treatment at the involved level. It is important to emphasize that the intention is only to categorize Structural and Compressive Pathology that is relevant to the patient's symptom complex. When more than one relevant structural or compressive lesion exists, the provider should select the most clinically relevant finding.

RESULTS

The interrater agreement was substantial for Symptoms (κ=0.70) and moderate for Structural Pathology (κ=0.58) and Compressive Pathology (κ=0.53). The intrarater agreement was substantial for Symptoms (κ=0.78), Structural Pathology (κ=0.70), or Compressive Pathology (κ=0.67).

CONCLUSIONS

This study demonstrates that improved diagnostic stratification of lumbar spine disorders is a feasible goal. The diagnostic coding matrix, based on clinically relevant descriptors, yielded substantial interrater consistency for symptoms, moderate interrater consistency for structural and compressive pathology, and substantial intrarater consistency for all elements.

Leg pain and psychological variables predict outcome 2-3 years after lumbar fusion surgery

Prediction studies testing a thorough range of psychological variables in addition to demographic, work-related and clinical variables are lacking in lumbar fusion surgery research. This prospective cohort study aimed at examining predictions of functional disability, back pain and health-related quality of life (HRQOL) 2-3 years after lumbar fusion by regressing nonlinear relations in a multivariate predictive model of pre-surgical variables. Before and 2-3 years after lumbar fusion surgery, patients completed measures investigating demographics, work-related variables, clinical variables, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, mental health and pain coping. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate predictor variables and address predictive model validity. The most parsimonious and stable subset of pre-surgical predictor variables explained 41.6, 36.0 and 25.6% of the variance in functional disability, back pain intensity and HRQOL 2-3 years after lumbar fusion. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical straight leg raise significantly predicted back pain. Post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL. For the median dichotomised classification of functional disability, back pain intensity and HRQOL levels 2-3 years post-surgery, the discriminative ability of the prediction models was of good quality. The results demonstrate the importance of pre-surgical psychological factors, leg pain intensity, straight leg raise and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL-related outcomes.