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Pozarek G, Strömqvist B, Ekvall Hansson E, Ahlström G. Pain and function in patients with chronic low back pain and leg pain after Zhineng Qigong - a quasi-experimental feasibility study. BMC Musculoskelet Disord 2023; 24:480. [PMID: 37312140 DOI: 10.1186/s12891-023-06581-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 05/30/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Qigong includes training for body and mind, one method is Zhineng Qigong. Scientific literature on qigong for chronic low back pain (LBP) is sparse. This study aimed to investigate feasibility including evaluation of a Zhineng Qigong intervention for pain and other lumbar spine-related symptoms, disability, and health-related quality of life in patients with chronic LBP and/or leg pain. METHODS Prospective interventional feasibility study without control group. Fifty-two chronic pain patients (18-75 years) with LBP and/or leg pain (Visual Analogue Scale ≥ 30) were recruited from orthopaedic clinics (spinal stenosis, spondylolisthesis, or segmental pain) and primary healthcare (chronic LBP). Patients from orthopaedic clinics were 1-6 years postoperative after lumbar spine surgery or on lumbar surgery waiting list. Patients received a 12-week training intervention with European Zhineng Qigong. The intervention consisted of face-to-face group activities in non-healthcare setting (4 weekends and 2 evenings per week), and individual Zhineng Qigong training. Main health outcomes were self-reported in a 14-day pain diary, Oswestry Disability Index (ODI), Short Form 36 version 2 (SF-36v2), and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L), once directly before and once directly after the intervention. RESULTS Recruitment rate was 11% and retention rate was 58%. Dropouts did not report higher pain (baseline), only 3 dropped out because of lumbar spine-related pain. Adherence was median 78 h group attendance (maximum 94 h) and 14 min daily individual training. Ability to collect outcomes was 100%. Thirty patients completed (mean 15 years symptom duration). Twenty-five had degenerative lumbar disorder, and 17 history of lumbar surgery. Results showed statistically significant (within-group) improvements in pain, ODI, all SF-36v2 scales, and EQ-5D-5L. CONCLUSIONS Despite low recruitment rate, recruitment was sufficient. A multicentre randomized controlled trial is proposed, with efforts to increase recruitment and retention rate. After this Zhineng Qigong intervention patients with chronic LBP and/or leg pain, also patients with considerable remaining LBP/sciatica after lumbar surgery, had significantly improved in pain and function. Results support involvement of postoperative patients in a future study. The results are promising, and this intervention needs to be further evaluated to provide the most reliable evidence. TRIAL REGISTRATION NCT04520334. Retrospectively registered 20/08/2020.
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Affiliation(s)
| | - Björn Strömqvist
- Departments of Clinical Sciences and Orthopaedics, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Gerd Ahlström
- Department of Health Sciences, Lund University, Lund, Sweden
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Kirker K, Masaracchio MF, Loghmani P, Torres-Panchame RE, Mattia M, States R. Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions. Physiother Theory Pract 2023; 39:241-286. [PMID: 34978252 DOI: 10.1080/09593985.2021.2012860] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions. OBJECTIVE The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS. METHODS Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted. RESULTS Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I2 = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms. CONCLUSIONS Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.
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Affiliation(s)
- Kaitlin Kirker
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | - Parisa Loghmani
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | - Michael Mattia
- Department of Allied Health, Kingsborough Community College, Brooklyn, NY, USA
| | - Rebecca States
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
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3
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Validity of outcome measures used in randomized clinical trials and observational studies in degenerative lumbar spinal stenosis. Sci Rep 2023; 13:1068. [PMID: 36658179 PMCID: PMC9852241 DOI: 10.1038/s41598-022-27218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023] Open
Abstract
It is unclear whether outcome measures used in degenerative lumbar spinal stenosis (DLSS) have been validated for this condition. Cross-sectional analysis of studies for DLSS included in systematic reviews (SA) and meta-analyses (MA) indexed in the Cochrane Library. We extracted all outcome measures for pain and disability. We assessed whether the studies provided external references for the validity of the outcome measures and the quality of the validation studies. Out of 20 SA/MA, 95 primary studies used 242 outcome measures for pain and/or disability. Most commonly used were the VAS (n = 69), the Oswestry Disability Index (n = 53) and the Zurich Claudication Questionnaire (n = 22). Although validation references were provided in 45 (47.3%) primary studies, only 14 validation studies for 9 measures (disability n = 7, pain and disability combined n = 2) were specifically validated in a DLSS population. The quality of the validation studies was mainly poor. The Zurich Claudication Questionnaire was the only disease specific tool with adequate validation for assessing treatment response in DLSS. To compare results from clinical studies, outcome measures need to be validated in a disease specific population. The quality of validation studies need to be improved and the validity in studies adequately cited.
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Özden F, Tümtürk İ, Yuvakgil Z, Sarı Z. The effectiveness of physical exercise in patients with lumbar spinal stenosis: a systematic review. SPORT SCIENCES FOR HEALTH 2022. [DOI: 10.1007/s11332-022-00895-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fornari M, Robertson SC, Pereira P, Zileli M, Anania CD, Ferreira A, Ferrari S, Gatti R, Costa F. Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100079. [PMID: 32613192 PMCID: PMC7322792 DOI: 10.1016/j.wnsx.2020.100079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.
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Affiliation(s)
- Maurizio Fornari
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Scott C. Robertson
- Neurosurgery Department, Laredo Medical Center, University of the Incarnate Word School of Osteopathic Medicine, Laredo, Texas, USA
| | - Paulo Pereira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
| | - Carla D. Anania
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ana Ferreira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | | | - Francesco Costa
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
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Yakovlev AE, Yakovleva MV, Chaykovskaya MK, Ardashev AV. [The First in Russia Experience of Successful Implementation of Constant Neurostimulation of the Spinal Cord in the Complex Treatment of a Patient with Permanent Form of Atrial Fibrillation Combined with Spinal Stenosis]. ACTA ACUST UNITED AC 2019; 59:83-90. [PMID: 31540579 DOI: 10.18087/cardio.2019.9.10272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/18/2022]
Abstract
This article describes for the first time in the domestic literature a clinical case of the therapeutic effect of neuromodulation on the permanent form of atrial fibrillation and chronic heart failure in an elderly patient with spinal stenosis which led to the development of pain syndrome and movement disorders. For the treatment of neurological pathology, at the beginning epidural administration of drugs was applied, followed by spinal cord stimulation trial and implantation of permanent neurostimulator. At each stage of treatment conducted by a functional neurosurgeon the patient had a spontaneous restoration of sinus rhythm, and during continuous neurostimulation a stable retention of sinus rhythm and regression of heart failure symptoms have been observed throughout a long observation period. The article also presents the data of a few experimental and clinical studies on the use of neuromodulation in cardiology, describes the method of implantation of spinal electrodes and analyzes possible mechanisms of modulation of the autonomic innervation of the heart, implemented by spinal cord stimulation.
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Affiliation(s)
- A E Yakovlev
- National Medical and Research Center of Traumatology and Orthopaedics N. N. Priorov
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Ammendolia C, Côté P, Rampersaud YR, Southerst D, Schneider M, Ahmed A, Bombardier C, Hawker G, Budgell B. Effect of active TENS versus de-tuned TENS on walking capacity in patients with lumbar spinal stenosis: a randomized controlled trial. Chiropr Man Therap 2019; 27:24. [PMID: 31244992 PMCID: PMC6582553 DOI: 10.1186/s12998-019-0245-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/26/2019] [Indexed: 01/03/2023] Open
Abstract
Background context Lumbar spinal stenosis (LSS) leads to diminished blood flow to the spinal nerves causing neurogenic claudication and impaired walking ability. Animal studies have demonstrated increased blood flow to the spinal nerves and spinal cord with superficial para-spinal electrical stimulation of the skin. Purpose The aim of this study was to assess the effectiveness of active para-spinal transcutaneous electrical nerve stimulation (TENS) compared to de-tuned TENS applied while walking, on improving walking ability in LSS. Study design This was a two-arm double-blinded (participant and assessor) randomized controlled trial. Patient sample We recruited 104 participants 50 years of age or older with neurogenic claudication, imaging confirmed LSS and limited walking ability. Outcome measures The primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals. Methods The active TENS group (n = 49) received para-spinal TENS from L3-S1 at a frequency of 65-100 Hz modulated over 3-s intervals with a pulse width of 100-200 usec, and turned on 2 min before the start and maintained during the SPWT. The de-tuned TENS group (n = 51) received similarly applied TENS for 30 s followed by ramping down to zero stimulus and turned off before the start and during the SPWT.Study funded by The Arthritis Society ($365,000 CAN) and salary support for Carlo Ammendolia funded by the Canadian Chiropractic Research Foundation ($500,000 CAN over 5 years). Results From August 2014 to January 2016 a total of 640 potential participants were screened for eligibility; 106 were eligible and 104 were randomly allocated to active TENS or de-tuned TENS. Both groups showed significant improvement in walking distance but there was no significant difference between groups. The mean difference between active and de-tuned TENS groups was 46.9 m; 95% CI (- 118.4 to 212.1); P = 0.57. A total of 71% (35/49) of active TENS and 74% (38/51) of de-tuned TENS participants achieved at least 30% improvement in walking distance; relative risk (RR), 0.96; 95% CI, (0.7 to 1.2) P = 0.77. Conclusions Active TENS applied while walking is no better than de-tuned TENS for improving walking ability in patients with degenerative LSS and therefore should not be a recommended treatment in clinical practice. Registration ClinicalTrials.gov ID: NCT02592642. Registration October 30, 2015.
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Affiliation(s)
- Carlo Ammendolia
- 1Institute of Health Policy, Management and Evaluation, University of Toronto, 60 Murray Street, Rm L2-225, Toronto, Ontario M5T 3L9 Canada.,2Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, 60 Murray Street, Rm L2-225, Toronto, Ontario M5T 3L9 Canada
| | - Pierre Côté
- 1Institute of Health Policy, Management and Evaluation, University of Toronto, 60 Murray Street, Rm L2-225, Toronto, Ontario M5T 3L9 Canada.,3Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,4UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology, Toronto, Ontario Canada
| | - Y Raja Rampersaud
- Department of Orthopedics, Toronto Western Hospital, University Health Network, 399 Bathurst Street, 441, 1 East Wing, Toronto, Ontario M5T 2S8 Canada
| | - Danielle Southerst
- 6Occupational and Industrial Orthopaedic Centre, Department of Orthopaedic Surgery, NYU Langone Health, 63 Downing Street, New York, NY 10014 USA
| | - Michael Schneider
- 7Department of Physical Therapy, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219 USA
| | - Aksa Ahmed
- 2Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, 60 Murray Street, Rm L2-225, Toronto, Ontario M5T 3L9 Canada
| | - Claire Bombardier
- 8Department of Medicine, Division of Rheumatology, University of Toronto, 190 Elizabeth Street, Suite RFE 3-805, Toronto, Ontario M5G 2C4 Canada.,9Department of Medicine, Faculty of Medicine, University of Toronto, P.O. Box 7, 60 Murray Street, Rm L2-008, Toronto, Ontario M5T 3L9 Canada
| | - Gillian Hawker
- 8Department of Medicine, Division of Rheumatology, University of Toronto, 190 Elizabeth Street, Suite RFE 3-805, Toronto, Ontario M5G 2C4 Canada.,9Department of Medicine, Faculty of Medicine, University of Toronto, P.O. Box 7, 60 Murray Street, Rm L2-008, Toronto, Ontario M5T 3L9 Canada
| | - Brian Budgell
- 10Canadian Memorial Chiropractic College, 6100 Leslie Street, North York, Ontario M2H 3J1 Canada
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Clinical Outcomes in Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Study of 49 Patients With Prospective Long-term Follow-up. J Manipulative Physiol Ther 2019; 42:203-209. [PMID: 31029469 DOI: 10.1016/j.jmpt.2018.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/10/2018] [Accepted: 11/02/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to assess long-term outcomes of a 6-week multimodal program (manual therapy, exercises, and self-management strategies) in patients with neurogenic claudication due to degenerative lumbar spinal stenosis. METHODS This study evaluated 49 patients with neurogenic claudication who completed a 6-week multimodal program between 2010 and 2013. Outcomes included Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Rating Scale. Mean differences, paired t tests, and the Wilcoxon rank-sum test were used to compare outcomes at baseline, 6 weeks, and long-term follow-up. RESULTS Twenty-three patients completed the follow-up questionnaire (47% response rate). Median follow-up was 3.6 years (interquartile range: 3.3-4.6). The mean age was 73.5 years (standard deviation: 8.5). Between baseline and long-term follow-up, there were statistically significant and clinically important improvements in disability (ODI: -23.7 [95% confidence interval (CI): -15.7 to -31.6]; ODI walking item: -1.96 [95% CI: -1.34 to -2.57]; ZCQ function scale: -0.42 [95% CI: -0.10 to -0.70]) and pain (leg pain: -3.53 [95% CI: -1.80 to -5.20]; ZCQ symptom scale: -0.71 [95% CI: -0.30 to -1.10]), but not low back pain (Numeric Rating Scale: -1.03 [95% CI: -1.00 to 3.10]). There was no statistically significant change in any outcomes between 6 weeks and long-term follow-up. CONCLUSION In a sample of patients with neurogenic claudication participating in a 6-week multimodal program, clinically important improvements in leg pain and disability, but not low back pain while walking, were maintained in the long term (median duration of 3.6 years) when compared to baseline.
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Chen L, H Ferreira P, R Beckenkamp P, L Ferreira M. Comparative efficacy and safety of surgical and invasive treatments for adults with degenerative lumbar spinal stenosis: protocol for a network meta-analysis and systematic review. BMJ Open 2019; 9:e024752. [PMID: 30948574 PMCID: PMC6500367 DOI: 10.1136/bmjopen-2018-024752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Surgical and invasive procedures are widely used in adults with degenerative lumbar spinal stenosis when conservative treatments fail. However, little is known about the comparative efficacy and safety of these interventions. To address this, we will perform a network meta-analysis (NMA) and systematic review to compare the efficacy and safety of surgical and invasive procedures for adults with degenerative lumbar spinal stenosis. METHODS AND ANALYSIS We will include randomised controlled trials assessing surgical and invasive treatments for adults with degenerative lumbar spinal stenosis. We will search AMED, CINAHL, EMBASE, the Cochrane Library and MEDLINE. Only English studies will be included and no restriction will be set for publication status. For efficacy, our primary outcome will be physical function. Secondary outcomes will include pain intensity, health-related quality of life, global impression of recovery, work absenteeism and mobility. For safety, our primary outcome will be all-cause mortality. Secondary outcomes will include adverse events (number of events or number of people with an event) and treatment withdrawal due to adverse effect. Two reviewers will independently select studies, extract data and assess the risk of bias (Revised Cochrane risk-of-bias tool for randomized trials) of included studies. The quality of the evidence will be evaluated through the Grading of Recommendations Assessment, Development and Evaluation framework. Random-effects NMA will be performed to combine all the evidence under the frequentist framework and the ranking results will be presented through the surface under the cumulative ranking curve and mean rank. All analyses will be performed in Stata and R. ETHICS AND DISSEMINATION No ethical approval is required. The research will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018094180.
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Affiliation(s)
- Lingxiao Chen
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paulo H Ferreira
- University of Sydney, Faculty of Health Sciences, Discipline of Physiotherapy, Sydney, New South Wales, Australia
| | - Paula R Beckenkamp
- University of Sydney, Faculty of Health Sciences, Discipline of Physiotherapy, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Ward L, Williamson E, Hansen Z, French DP, Boniface G, Rogers D, Lamb SE. Development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention for older adults with neurogenic claudication. Physiotherapy 2019; 105:262-274. [PMID: 30935673 DOI: 10.1016/j.physio.2019.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 01/29/2019] [Indexed: 11/29/2022]
Abstract
Neurogenic claudication due to spinal stenosis is a common cause of disability in older adults. Conservative treatments are a favourable treatment option. This paper describes the development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention, a physiotherapist-delivered physical and psychological intervention for the management of neurogenic claudication in older adults. The BOOST intervention is being tested in a multi-centre, randomised controlled trial in UK National Health Service Trusts; delivered by physiotherapists registered with the Health and Care Professionals Council. Participants are aged 65 years or older, registered with a primary care practice, and report symptoms consistent with neurogenic claudication. Intervention content and delivery was initially informed by clinical and patient experts, research evidence, and behaviour change guidelines; and refined following an intervention development day attended by researchers, health professionals, and Patient and Public Involvement representatives. The BOOST intervention comprises 12 group sessions, promoting sustained adherence with a long term home and physical activity programme. Each session includes education and group discussion, individually tailored exercises, and walking. Initial exercise levels are set at a one-to-one assessment. Continued home exercise adherence and increased physical activity following completion of the sessions is facilitated through support telephone calls. Trial registration ISRCTN12698674.
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Affiliation(s)
- Lesley Ward
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK.
| | - Esther Williamson
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK.
| | - Zara Hansen
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK.
| | - David P French
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Coupland 1 Building, Oxford Road, Manchester M13 9PL, UK.
| | - Graham Boniface
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK.
| | - David Rogers
- Centre for Musculoskeletal Medicine, Royal Orthopaedic Hospital NHS Foundation Trust Birmingham, Bristol Road South, Birmingham B31 2AP, UK.
| | - Sarah E Lamb
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK.
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Kim K, Shin KM, Hunt CL, Wang Z, Bauer BA, Kwon O, Lee JH, Seo BN, Jung SY, Youn Y, Lee SH, Choi JC, Jung JE, Kim J, Qu W, Kim TH, Eldrige JS. Nonsurgical integrative inpatient treatments for symptomatic lumbar spinal stenosis: a multi-arm randomized controlled pilot trial. J Pain Res 2019; 12:1103-1113. [PMID: 30992679 PMCID: PMC6445233 DOI: 10.2147/jpr.s173178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Lumbar spinal stenosis (LSS) is a chronic condition that causes low back pain and neurogenic claudication, often resulting in significant limitation of daily activities. In this open-label randomized controlled pilot study, we assessed the safety and feasibility of 4-week novel integrative inpatient treatments for LSS. Methods Thirty-six symptomatic LSS patients were randomly and equally allocated to one of the three groups: Mokhuri Chuna treatment 1 (MT1) group, Mokhuri Chuna treatment 2 (MT2) group, or conventional management treatment (CMT) group. MT1 patients were treated with herbal medication, Mokhuri Chuna, and acupuncture, and received daily physician consultation; MT2 patients were treated with Mokhuri Chuna and acupuncture without any herbal medication, and received daily physician consultation; and CMT patients received conventional pain management therapy that included epidural steroid injection, oral NSAID, and muscle relaxant medication, along with daily physiotherapy. The primary outcome of this pilot study was safety as measured by the type and incidence of adverse events (AEs). The secondary outcome measures included VAS score for low back pain and leg pain, Oswestry Disability Index, Oxford Claudication Score (OCS), walking capacity on a 50 m flat track and treadmill, and EuroQol-5D score. Magnetic resonance imaging was also performed up to 6 months after treatment cessation. Results Thirty-four treated patients were included in the analysis, based on the modified intention-to-treat principle. No serious AEs were observed or reported. Compared to the CMT group, the MT1 and MT2 groups did show significant improvement at 3 and 6 months in various domains, including pain (VAS score for leg and back pain) and function (OCS and treadmill walking). Conclusion These novel multimodal integrative treatments for LSS are both clinically safe and logistically feasible. Larger, adequately powered randomized controlled trials will be necessary to assess comparative efficacy and thoroughly analyze the cost-effectiveness of each treatment approach. Clinical trial registration number (CRIS) KCT0001218.
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Affiliation(s)
- Kiok Kim
- Department of Spine Center, Mokhuri Neck & Back Hospital, Seoul, South Korea
| | - Kyung-Min Shin
- Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Christy L Hunt
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Brent A Bauer
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ojin Kwon
- Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Jun-Hwan Lee
- Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, South Korea.,Korean Medicine Life Science, Campus of Korea Institute of Oriental Medicine, University of Science & Technology (UST), Daejeon, South Korea
| | - Bok-Nam Seo
- Future Medicine Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - So-Young Jung
- Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Yousuk Youn
- Department of Spine Center, Mokhuri Neck & Back Hospital, Seoul, South Korea
| | - Sang Ho Lee
- Department of Spine Center, Mokhuri Neck & Back Hospital, Seoul, South Korea
| | - Jung Chul Choi
- Department of Spine Center, Mokhuri Neck & Back Hospital, Seoul, South Korea
| | - Jae Eun Jung
- Hongik Neurosurgery Hospital, Seongnam, South Korea
| | - Jaehong Kim
- Department of Spine Center, Mokhuri Neck & Back Hospital, Seoul, South Korea
| | - Wenchun Qu
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA.,Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA,
| | - Tae-Hun Kim
- Korean Medicine Clinical Trial Center, Korean Medicine Hospital, Kyung Hee University, Seoul, South Korea
| | - Jason S Eldrige
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA,
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Ammendolia C, Rampersaud YR, Southerst D, Ahmed A, Schneider M, Hawker G, Bombardier C, Côté P. Effect of a prototype lumbar spinal stenosis belt versus a lumbar support on walking capacity in lumbar spinal stenosis: a randomized controlled trial. Spine J 2019; 19:386-394. [PMID: 30053521 DOI: 10.1016/j.spinee.2018.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar spinal stenosis (LSS) can impair blood flow to the spinal nerves giving rise to neurogenic claudication and limited walking ability. Reducing lumbar lordosis can increases the volume of the spinal canal and reduce neuroischemia. We developed a prototype LSS belt aimed at reducing lumbar lordosis while walking. PURPOSE The aim of this study was to assess the short-term effectiveness of a prototype LSS belt compared to a lumbar support in improving walking ability in patients with degenerative LSS. STUDY DESIGN This was a two-arm, double-blinded (participant and assessor) randomized controlled trial. PATIENT SAMPLE We recruited 104 participants aged 50 years or older with neurogenic claudication, imaging confirmed degenerative LSS, and limited walking ability. OUTCOME MEASURES The primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals. METHODS Within 1 week of a baseline SPWT, participants randomized to the prototype LSS belt group (n=52) and those randomized to the lumbar support group (n=52) performed a SPWT that was conducted by a blinded assessor. The Arthritis Society funded this study ($365,000 CAN) with salary support for principal investigator funded by the Canadian Chiropractic Research Foundation ($500,000 CAN for 5 years). RESULTS Both groups showed significant improvement in walking distance, but there was no significant difference between groups. The mean group difference in walking distance was -74 m (95% CI: -282.8 to 134.8, p=.49). In total, 62% of participants wearing the prototype LSS belt and 82% of participants wearing the lumbar support achieved at least 30% improvement in walking distance (relative risk, 0.7; 95% CI: 0.5-1.3, p=.43). CONCLUSIONS A prototype LSS belt demonstrated significant improvement in walking ability in degenerative LSS but was no better than a lumbar support.
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Affiliation(s)
- Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON Canada M5T 3M6; Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, 60 Murray Street, Room L2-225, Toronto, Ontario M5T 3L9, Canada.
| | - Y Raja Rampersaud
- Department of Orthopedics, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON Canada M5T 2S8
| | - Danielle Southerst
- Occupational and Industrial Center, Department of Orthopaedic Surgery, NYU Langone Health, 63 Downing St. New York, NY 10014, USA
| | - Aksa Ahmed
- Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, 60 Murray Street, Room L2-225, Toronto, Ontario M5T 3L9, Canada
| | - Michael Schneider
- Department of Physical Therapy, University of Pittsburgh, 4028 Forbes Tower Pittsburgh, PA 15260, USA
| | - Gillian Hawker
- Department of Medicine, Division of Rheumatology, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, Ontario, Canada, M5S 1A8; Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, Ontario, Canada M5S 1A8
| | - Claire Bombardier
- Department of Medicine, Division of Rheumatology, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, Ontario, Canada, M5S 1A8; Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, Ontario, Canada M5S 1A8
| | - Pierre Côté
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON Canada M5T 3M6; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Ontario, Canada, M5T 3M7; UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North Oshawa, Ontario, Canada L1H 7K4
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Anderson DB, Ferreira ML, Harris IA, Davis GA, Stanford R, Beard D, Li Q, Jan S, Mobbs RJ, Maher CG, Yong R, Zammit T, Latimer J, Buchbinder R. SUcceSS, SUrgery for Spinal Stenosis: protocol of a randomised, placebo-controlled trial. BMJ Open 2019; 9:e024944. [PMID: 30765407 PMCID: PMC6398750 DOI: 10.1136/bmjopen-2018-024944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/12/2018] [Accepted: 12/12/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Central lumbar spinal stenosis (LSS) is a common cause of pain, reduced function and quality of life in older adults. Current management of LSS includes surgery to decompress the spinal canal and alleviate symptoms. However, evidence supporting surgical decompression derives from unblinded randomised trials with high cross-over rates or cohort studies showing modest benefits. This protocol describes the design of the SUrgery for Spinal Stenosis (SUcceSS) trial -the first randomised placebo-controlled trial of decompressive surgery for symptomatic LSS. METHODS AND ANALYSIS SUcceSS will be a prospectively registered, randomised placebo-controlled trial of decompressive spinal surgery. 160 eligible participants (80 participants/group) with symptomatic LSS will be randomised to either surgical spinal decompression or placebo surgical intervention. The placebo surgical intervention is identical to surgical decompression in all other ways with the exception of the removal of any bone or ligament. All participants and assessors will be blinded to treatment allocation. Outcomes will be assessed at baseline and at 3, 6, 12 and 24 months. The coprimary outcomes will be function measured with the Oswestry Disability Index and the proportion of participants who have meaningfully improved their walking capacity at 3 months postrandomisation. Secondary outcomes include back pain intensity, lower limb pain intensity, disability, quality of life, anxiety and depression, neurogenic claudication score, perceived recovery, treatment satisfaction, adverse events, reoperation rate and rehospitalisation rate. Those who decline to be randomised will be invited to participate in a parallel observational cohort. Data analysis will be blinded and by intention to treat. A trial-based cost-effectiveness analysis will determine the potential incremental cost per quality-adjusted life year gained. ETHICS AND DISSEMINATION Ethics approval has been granted by the NSW Health (reference:17/247/POWH/601) and the Monash University (reference: 12371) Human Research Ethics Committees. Dissemination of results will be via journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12617000884303; Pre-results.
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Affiliation(s)
- David B Anderson
- Insitute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Insitute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales, St Leonards, New South Wales, Australia
| | - Gavin A Davis
- Department of Neurosurgery, Austin Health, Heidelberg, New South Wales, Australia
- Department of Neurosurgery, Cabrini Hospital, Malvern, Victoria, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, NIHR Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ralph J Mobbs
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Christopher G Maher
- School of Public Health, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Renata Yong
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tara Zammit
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane Latimer
- School of Public Health, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Can Percutaneous Biportal Endoscopic Surgery Achieve Enough Canal Decompression for Degenerative Lumbar Stenosis? Prospective Case–Control Study. World Neurosurg 2018; 120:e684-e689. [DOI: 10.1016/j.wneu.2018.08.144] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 11/21/2022]
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Williamson E, Ward L, Vadher K, Dutton SJ, Parker B, Petrou S, Hutchinson CE, Gagen R, Arden NK, Barker K, Boniface G, Bruce J, Collins G, Fairbank J, Fitch J, French DP, Garrett A, Gandhi V, Griffiths F, Hansen Z, Mallen C, Morris A, Lamb SE. Better Outcomes for Older people with Spinal Trouble (BOOST) Trial: a randomised controlled trial of a combined physical and psychological intervention for older adults with neurogenic claudication, a protocol. BMJ Open 2018; 8:e022205. [PMID: 30341124 PMCID: PMC6196848 DOI: 10.1136/bmjopen-2018-022205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/21/2018] [Accepted: 08/30/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Neurogenic claudication due to spinal stenosis is common in older adults. The effectiveness of conservative interventions is not known. The aim of the study is to estimate the clinical and cost-effectiveness of a physiotherapist-delivered, combined physical and psychological intervention. METHODS AND ANALYSIS This is a pragmatic, multicentred, randomised controlled trial. Participants are randomised to a combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme) or best practice advice (control). Community-dwelling adults, 65 years and over, with neurogenic claudication are identified from community and secondary care services. Recruitment is supplemented using a primary care-based cohort. Participants are registered prospectively and randomised in a 2:1 ratio (intervention:control) using a web-based service to ensure allocation concealment. The target sample size is a minimum of 402. The BOOST programme consists of an individual assessment and twelve 90 min classes, including education and discussion underpinned by cognitive behavioural techniques, exercises and walking circuit. During and after the classes, participants undertake home exercises and there are two support telephone calls to promote adherence with the exercises. Best practice advice is delivered in one to three individual sessions with a physiotherapist. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the 6 Minute Walk Test, Short Physical Performance Battery, Fear Avoidance Beliefs Questionnaire and Gait Self-Efficacy Scale. Outcomes are measured at 6 and 12 months by researchers who are masked to treatment allocation. The primary statistical analysis will be by 'intention to treat'. There is a parallel health economic evaluation and qualitative study. ETHICS AND DISSEMINATION Ethical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials checklist. The results will be reported at conferences and in peer-reviewed publications using the Consolidated Standards of Reporting Trials guidelines. A plain English summary will be published on the BOOST website. TRIAL REGISTRATION NUMBER ISRCTN12698674; Pre-results.
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Affiliation(s)
- Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Lesley Ward
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Karan Vadher
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ben Parker
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Richard Gagen
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Graham Boniface
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Julie Bruce
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gary Collins
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jeremy Fairbank
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Judith Fitch
- Patient and Public Involvement Representative, Yorkshire, UK
| | - David P French
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Manchester, UK
| | - Angela Garrett
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Varsha Gandhi
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Zara Hansen
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Alana Morris
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Caporlingua F. Editorial on: "Superion ® InterSpinous Spacer Treatment of Moderate Spinal Stenosis: 4-year Results". JOURNAL OF SPINE SURGERY (HONG KONG) 2018; 4:666-667. [PMID: 30547136 PMCID: PMC6261762 DOI: 10.21037/jss.2018.08.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/13/2018] [Indexed: 06/09/2023]
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Kundakci B, Sultana A, Taylor AJ, Alshehri MA. The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness: A systematic review. F1000Res 2018; 7:276. [PMID: 29862019 PMCID: PMC5954334 DOI: 10.12688/f1000research.14089.1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 01/30/2023] Open
Abstract
Background: Dizziness is a non-specific term used by patients to describe several symptoms ranging from true vertigo, light headedness, disorientation or sense of imbalance. Vestibular rehabilitation (VR) is a specific form of exercise-based therapy programme aimed at alleviating the primary and secondary problems of a vestibular pathology. The aim of this study was to investigate the effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness. Methods: The following five databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE, PubMed, the Physiotherapy Evidence Database (PEDro) and Scopus (Elsevier). Two investigators independently reviewed all articles and a systematic review of literature was performed using the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The articles were included if they met the following inclusion criteria: (1) randomised controlled trial, (2) people with chronic dizziness, (3) adults aged 18 or over, (4) exercise-based VR, (5) VR exercises compared with sham or usual care, non-treatment or placebo and (6) only studies published full text in English. Results: The initial search identified 304 articles, four of which met the criteria for analysis. All studies involved some form of vestibular rehabilitation, including vestibular compensation, vestibular adaptation and substitution exercises. These exercises were compared with usual medical care (three studies) or placebo eye exercise (one study). The Vertigo Symptom Scale was the most commonly used outcome measure to assess subjective perception of symptoms of dizziness (three studies). According to the PEDro scale, three studies were considered to be of high quality, and one was rated as fair. Conclusions: This review suggests that exercise-based vestibular rehabilitation shows benefits for adult patients with chronic dizziness with regard to improvement in the vertigo symptom scale, fall risk, balance and emotional status.
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Affiliation(s)
- Burak Kundakci
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, NG7 2RD, UK.,Physiotherapy and Rehabilitation, Faculty of Health Sciences, Ordu University , Ordu, Turkey
| | - Anjum Sultana
- Division of Physiotherapy, School of Health Sciences, University of Nottingham, Nottingham, Nottinghamshire , NG7 2RD, UK
| | - Alan J Taylor
- Division of Physiotherapy, School of Health Sciences, University of Nottingham, Nottingham, Nottinghamshire , NG7 2RD, UK
| | - Mansour Abdullah Alshehri
- Physiotherapy Department, Faculty of Applied Medical Sciences, Umm-Al-Qura University, Mecca, 21421, Saudi Arabia
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Evaluation of a polyetheretherketone (PEEK) titanium composite interbody spacer in an ovine lumbar interbody fusion model: biomechanical, microcomputed tomographic, and histologic analyses. Spine J 2017; 17:1907-1916. [PMID: 28751242 DOI: 10.1016/j.spinee.2017.06.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/26/2017] [Accepted: 06/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The most commonly used materials used for interbody cages are titanium metal and polymer polyetheretherketone (PEEK). Both of these materials have demonstrated good biocompatibility. A major disadvantage associated with solid titanium cages is their radiopacity, limiting the postoperative monitoring of spinal fusion via standard imaging modalities. However, PEEK is radiolucent, allowing for a temporal assessment of the fusion mass by clinicians. On the other hand, PEEK is hydrophobic, which can limit bony ingrowth. Although both PEEK and titanium have demonstrated clinical success in obtaining a solid spinal fusion, innovations are being developed to improve fusion rates and to create stronger constructs using hybrid additive manufacturing approaches by incorporating both materials into a single interbody device. PURPOSE The purpose of this study was to examine the interbody fusion characteristic of a PEEK Titanium Composite (PTC) cage for use in lumbar fusion. STUDY DESIGN/SETTING Thirty-four mature female sheep underwent two-level (L2-L3 and L4-L5) interbody fusion using either a PEEK or a PTC cage (one of each per animal). Animals were sacrificed at 0, 8, 12, and 18 weeks post surgery. MATERIALS AND METHODS Post sacrifice, each surgically treated functional spinal unit underwent non-destructive kinematic testing, microcomputed tomography scanning, and histomorphometric analyses. RESULTS Relative to the standard PEEK cages, the PTC constructs demonstrated significant reductions in ranges of motion and a significant increase in stiffness. These biomechanical findings were reinforced by the presence of significantly more bone at the fusion site as well as ingrowth into the porous end plates. CONCLUSIONS Overall, the results indicate that PTC interbody devices could potentially lead to a more robust intervertebral fusion relative to a standard PEEK device in a clinical setting.
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Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up. Spine (Phila Pa 1976) 2017; 42:E1077-E1086. [PMID: 28092340 DOI: 10.1097/brs.0000000000002068] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospective, multicenter cohort study. OBJECTIVE To estimate the added effect of surgical fusion as compared to decompression surgery alone in symptomatic lumbar spinal stenosis patients with spondylolisthesis. SUMMARY OF BACKGROUND DATA The optimal surgical management of lumbar spinal stenosis patients with spondylolisthesis remains controversial. METHODS Patients of the Lumbar Stenosis Outcome Study with confirmed DLSS and spondylolisthesis were enrolled in this study. The outcomes of this study were Spinal Stenosis Measure (SSM) symptoms (score range 1-5, best-worst) and function (1-4) over time, measured at baseline, 6, 12, 24, and 36 months follow-up. In order to quantify the effect of fusion surgery as compared to decompression alone and number of decompressed levels, we used mixed effects models and accounted for the repeated observations in main outcomes (SSM symptoms and SSM function) over time. In addition to individual patients' random effects, we also fitted random slopes for follow-up time points and compared these two approaches with Akaike's Information Criterion and the chi-square test. Confounders were adjusted with fixed effects for age, sex, body mass index, diabetes, Cumulative Illness Rating Scale musculoskeletal disorders, and duration of symptoms. RESULTS One hundred thirty-one patients undergoing decompression surgery alone (n = 85) or decompression with fusion surgery (n = 46) were included in this study. In the multiple mixed effects model the adjusted effect of fusion compared with decompression alone surgery on SSM symptoms was 0.06 (95% confidence interval: -0.16-0.27) and -0.07 (95% confidence interval: -0.25-0.10) on SSM function, respectively. CONCLUSION Among the patients with degenerative lumbar spinal stenosis and spondylolisthesis our study confirms that in the two groups, decompression alone and decompression with fusion, patients distinctively benefited from surgical treatment. When adjusted for confounders, fusion surgery was not associated with a more favorable outcome in both SSM scores as compared to decompression alone surgery. LEVEL OF EVIDENCE 3.
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Machado GC, Ferreira PH, Yoo RIJ, Harris IA, Pinheiro MB, Koes BW, van Tulder MW, Rzewuska M, Maher CG, Ferreira ML. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev 2016; 11:CD012421. [PMID: 27801521 PMCID: PMC6464992 DOI: 10.1002/14651858.cd012421] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear. OBJECTIVES To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates. SEARCH METHODS Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews. SELECTION CRITERIA This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'. AUTHORS' CONCLUSIONS The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.
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Affiliation(s)
- Gustavo C Machado
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Rafael IJ Yoo
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW AustraliaIngham Institute for Applied Medical ResearchElizabeth StreetLiverpoolNew South WalesAustralia2170
| | - Marina B Pinheiro
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Bart W Koes
- Erasmus Medical CenterDepartment of General PracticePO Box 2040RotterdamNetherlands3000 CA
| | - Maurits W van Tulder
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
| | - Magdalena Rzewuska
- University of São PauloDepartment of Social Medicine, Faculty of MedicineAv. Bandeirantes, 3900 ‐ Monte AlegreRibeirão PretoSão PauloBrazil
| | - Christopher G Maher
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyThe George Institute for Global Health & Institute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
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Effect of TENS Versus Placebo on Walking Capacity in Patients With Lumbar Spinal Stenosis: A Protocol for a Randomized Controlled Trial. J Chiropr Med 2016; 15:197-203. [PMID: 27660596 PMCID: PMC5021899 DOI: 10.1016/j.jcm.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 11/26/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) is a growing health problem and a leading cause of disability and loss of independence in older adults. It is usually caused by age-related degenerative narrowing of the spinal canals leading to compression and ischemia of the spinal nerves and symptoms of neurogenic claudication. Limited walking ability is the dominant functional impairment caused by LSS. Animal studies suggest increased blood flow to the spinal nerves and spinal cord with superficial paraspinal electrical stimulation. The purpose of this study is to assess the effectiveness of paraspinal transcutaneous electrical nerve stimulation (TENS) applied while walking on walking ability in patients with LSS. Methods/Design We propose to conduct a 2-arm double-blinded (participant and assessor) randomized controlled trial. We will recruit individuals who have limited walking ability due to degenerative LSS from hospital specialists, community physicians, and chiropractors located in the city of Toronto, Canada. Eligible consenting participants will be randomly assigned to either paraspinal TENS or placebo paraspinal TENS applied while walking. The primary outcome will be walking distance measured during a single self-paced walking test. We will calculate the differences in proportions among participants in both groups who achieve at least a 30% improvement in walking distance from baseline using Pearson χ2 test with 95% confidence intervals. Discussion Effective nonoperative interventions for LSS are unknown. Interventions that can improve blood flow to the spinal nerves while walking may increase walking ability in this population. Transcutaneous electrical nerve stimulation is a low-cost intervention that may have the potential to achieve this objective. To our knowledge, this study will be the first clinical trial to assess the effects of TENS on walking ability of patients with LSS. Trial Registration ClinicalTrials.gov ID: NCT02592642
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Ammendolia C, Côté P, Rampersaud YR, Southerst D, Budgell B, Bombardier C, Hawker G. The boot camp program for lumbar spinal stenosis: a protocol for a randomized controlled trial. Chiropr Man Therap 2016; 24:25. [PMID: 27433335 PMCID: PMC4948101 DOI: 10.1186/s12998-016-0106-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/08/2016] [Indexed: 01/22/2023] Open
Abstract
Background Lumbar spinal stenosis (LSS) causing neurogenic claudication is a leading cause of pain, disability and loss of independence in older adults. The prevalence of lumbar spinal stenosis is growing rapidly due to an aging population. The dominant limitation in LSS is walking ability. Postural, physical and psychosocial factors can impact symptoms and functional ability. LSS is the most common reason for spine surgery in older adults yet the vast majority of people with LSS receive non-surgical treatment. What constitutes effective non-surgical treatment is unknown. The purpose of this study is to evaluate the effectiveness of a multi-modal and self-management training program, known as the Boot Camp Program for LSS aimed at improving walking ability and other relevant patient-centred outcomes. Methods We will use a pragmatic two-arm randomized controlled single blinded (assessor) study design. Eligible and consenting participants will be randomized to receive from licensed chiropractors either a 6-week (twice weekly) self-management training program (manual therapy, education, home exercises) with an instructional workbook and video and a pedometer or a single instructional session with an instructional workbook and video and pedometer. The main outcome measure will be the self-paced walking test measured at 6 months. We will also assess outcomes at 8 weeks and 3 and 12 months. Discussion Symptoms and functional limitations in LSS are variable and influenced by changes in spinal alignment. Physical and psychological factors result in chronic disability for patients with LSS. The Boot Camp Program is a 6-week self-management training program aimed at the multi-faceted aspects of LSS and trains individuals to use self-management strategies. The goal is to provide life-long self-management strategies that maximize walking and overall functional abilities and quality of life. Trial registration ClinicalTrials.gov ID: NCT02592642.
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Affiliation(s)
- Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada ; Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, Toronto, Canada
| | - Pierre Côté
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada ; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada ; University of Ontario Institute of Technology, Ontario, Canada
| | - Y Raja Rampersaud
- Department of Orthopedics, Toronto Western Hospital, University Health Network, Toronto, Canada
| | | | - Brian Budgell
- Canadian Memorial Chiropractic College, Toronto, Ontario Canada
| | - Claire Bombardier
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada ; Department of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Gillian Hawker
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada ; Department of Medicine, University of Toronto, Toronto, Ontario Canada
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23
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Martins DE, Astur N, Kanas M, Ferretti M, Lenza M, Wajchenberg M. Quality assessment of systematic reviews for surgical treatment of low back pain: an overview. Spine J 2016; 16:667-75. [PMID: 26826347 DOI: 10.1016/j.spinee.2016.01.185] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 10/16/2015] [Accepted: 01/15/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Low back pain is one of the most frequent reasons for medical appointments. Surgical treatment is widely controversial, and new surgical techniques and treatment modalities have been developed within the last decade. Treatment for low back pain should be evidence-based through systematic reviews and meta-analysis. Thus, the quality of these reviews is sometimes put into question as methodological mistakes are frequently seen. PURPOSE The aim of this study was to gather all systematic reviews for the surgical treatment of low back pain and analyze their outcomes, quality, and conclusion. STUDY DESIGN/SETTING This is an overview of systematic reviews. OUTCOME MEASURES The outcome measures were the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) score, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, and conclusion supported by descriptive statistics. METHODS A literature search for systematic reviews containing low back pain surgical treatment was conducted through different medical databases. Two investigators independently assessed all titles and abstracts for inclusion. Studies should have at least one surgical procedure as an intervention. Diagnoses were categorized as lumbar disc herniation, spondylolisthesis, stenosis, facet joint syndrome, and degenerative disc disease. Quality was assessed through the PRISMA and AMSTAR questionnaires. Study quality related to its PRISMA or AMSTAR score percentage was rated as very poor (<30%), poor (30%-50%), fair (50%-70%), good (70%-90%), and excellent (>90%). Articles were considered conclusive if they had a conclusion for their primary outcome supported by descriptive statistical evidence. This study was funded exclusively by the authors' own resources. None of the authors have any potential conflict of interest to declare. RESULTS Overall, there were 40 systematic reviews included. According to AMSTAR and PRISMA scores, 5% to 7.5% of the systematic reviews were rated as excellent and most of them were rated as a fair review. AMSTAR indicated that 22.5% of the reviews have very poor quality, whereas PRISMA stated that 7.5% were of very poor quality. For both tools, performing a meta-analysis made the reviews' quality significantly better. The best-rated diagnosis groups according to PRISMA were spondylosis, lumbar disc herniation, and degenerative disc disease. Considering the studies' conclusions, 25 (62.5%) out of the 40 systematic reviews had a conclusion to their primary outcome, and only 11 (27.5%) were supported by descriptive statistical analysis. This means that 44% of the systematic reviews with a conclusion were evidence-based. There were 15 (37.5%) systematic reviews that did not reach a conclusion to their primary objectives. CONCLUSIONS In conclusion, most systematic reviews for low back pain do not reach very good or excellent quality, and only 27.5% of them have evidence-based conclusions. Including a meta-analysis is a significant factor to improve quality and evidence for systematic reviews.
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Affiliation(s)
- Delio Eulalio Martins
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627, Office 306, A1 Building, 05652-900 Sao Paulo, SP, Brazil.
| | - Nelson Astur
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627, Office 306, A1 Building, 05652-900 Sao Paulo, SP, Brazil
| | - Michel Kanas
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627, Office 306, A1 Building, 05652-900 Sao Paulo, SP, Brazil
| | - Mário Ferretti
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627, Office 306, A1 Building, 05652-900 Sao Paulo, SP, Brazil
| | - Mario Lenza
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627, Office 306, A1 Building, 05652-900 Sao Paulo, SP, Brazil
| | - Marcelo Wajchenberg
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627, Office 306, A1 Building, 05652-900 Sao Paulo, SP, Brazil
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Fernandez M, Ferreira ML, Refshauge KM, Hartvigsen J, Silva IRC, Maher CG, Koes BW, Ferreira PH. Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015. [PMID: 26210309 DOI: 10.1007/s00586-015-4148-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Previous reviews have compared surgical to non-surgical management of sciatica, but have overlooked the specific comparison between surgery and physical activity-based interventions. METHODS Systematic review using MEDLINE, CINAHL, Embase and PEDro databases was conducted. Randomised controlled trials comparing surgery to physical activity, where patients were experiencing the three most common causes of sciatica-disc herniation, spondylolisthesis and spinal stenosis. Two independent reviewers extracted pain and disability data (converted to a common 0-100 scale) and assessed methodological quality using the PEDro scale. The size of the effects was estimated for each outcome at three different time points, with a random effects model adopted and the GRADE approach used in summary conclusions. RESULTS Twelve trials were included. In the short term, surgery provided better outcomes than physical activity for disc herniation: disability [WMD -9.00 (95 % CI -13.73, -4.27)], leg pain [WMD -16.01 (95 % CI -23.00, -9.02)] and back pain [WMD -12.44 (95 % CI -17.76, -7.09)]; for spondylolisthesis: disability [WMD -14.60 (95 % CI -17.12, -12.08)], leg pain [WMD -35.00 (95 % CI -39.66, -30.34)] and back pain [WMD -20.00 (95 % CI -24.66, -15.34)] and spinal stenosis: disability [WMD -11.39 (95 % CI -17.31, -5.46)], leg pain [WMD, -27.17 (95 % CI -35.87, -18.46)] and back pain [WMD -20.80 (95 % CI -25.15, -16.44)]. Long-term and greater than 2-year post-randomisation results favoured surgery for spondylolisthesis and stenosis, although the size of the effects reduced with time. For disc herniation, no significant effect was shown for leg and back pain comparing surgery to physical activity. CONCLUSION There are indications that surgery is superior to physical activity-based interventions in reducing pain and disability for disc herniation at short-term follow-up only; but high-quality evidence in this field is lacking (GRADE). For spondylolisthesis and spinal stenosis, surgery is superior to physical activity up to greater than 2 years follow-up. Results should guide clinicians and patients when facing the difficult decision of having surgery or engaging in active care interventions. PROSPERO registration number : CRD42013005746.
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Affiliation(s)
- Matthew Fernandez
- Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia.
| | - Manuela L Ferreira
- The George Institute for Global Health, Sydney Medical School, University of Sydney, 321 Kent Street, Sydney, NSW, 2000, Australia.,The Institute of Bone and Joint Research, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kathryn M Refshauge
- Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M, Denmark
| | - Isabela R C Silva
- Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia
| | - Chris G Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, 321 Kent Street, Sydney, NSW, 2000, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus University Medical Centre, P.O. Box 2040, 3000, Rotterdam, The Netherlands
| | - Paulo H Ferreira
- Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia
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Burgstaller JM, Porchet F, Steurer J, Wertli MM. Arguments for the choice of surgical treatments in patients with lumbar spinal stenosis - a systematic appraisal of randomized controlled trials. BMC Musculoskelet Disord 2015; 16:96. [PMID: 25896506 PMCID: PMC4409719 DOI: 10.1186/s12891-015-0548-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/01/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis is the most common reason for spinal surgery in elderly patients. However, the surgical management of spinal stenosis is controversial. The aim of this review was to list aspects a surgeon considers when choosing a specific type of treatment. METHODS Appraisal of arguments reported in randomized controlled trials (RCTs) included in systematic reviews published or indexed in the Cochrane library studying surgical treatments in patients with spinal stenosis. RESULTS Eight out of nine RCTs listed arguments for the choice of their treatments under investigation. The argument for decompression alone was the high success rate, the argument against was a potential increase in vertebral instability. The argument for decompression and fusion without instrumentation was that it is a well-established technique with a high fusion success rate, the argument against it was that the indication for fusion in spinal stenosis has remained unclear. The argument for decompression and fusion with instrumentation was an increased fusion rate compared to decompression and fusion without instrumentation, the argument against this was that the invasive procedure is associated with more complications. CONCLUSIONS The main argument identified in this appraisal for and against decompression alone in patient with lumbar spinal stenosis was whether or not instability should be treated with (instrumented) fusion procedures. However, there is disagreement on how instability should be defined. In a first step it is important that researchers and clinicians agree on definitions for important key concepts such as instability and reoperations.
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Affiliation(s)
- Jakob M Burgstaller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland.
| | - François Porchet
- Department of Neurosurgery, Spine Center, Schulthess Clinic, Zürich, Switzerland.
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland.
| | - Maria M Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland.
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Machado GC, Ferreira PH, Harris IA, Pinheiro MB, Koes BW, van Tulder M, Rzewuska M, Maher CG, Ferreira ML. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One 2015; 10:e0122800. [PMID: 25822730 PMCID: PMC4378944 DOI: 10.1371/journal.pone.0122800] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 02/13/2015] [Indexed: 12/31/2022] Open
Abstract
Background The management of spinal stenosis by surgery has increased rapidly in the past two decades, however, there is still controversy regarding the efficacy of surgery for this condition. Our aim was to investigate the efficacy and comparative effectiveness of surgery in the management of patients with lumbar spinal stenosis. Methods Electronic searches were performed on MEDLINE, EMBASE, AMED, CINAHL, Web of Science, LILACS and Cochrane Library from inception to November 2014. Hand searches were conducted on included articles and relevant reviews. We included randomised controlled trials evaluating surgery compared to no treatment, placebo/sham, or to another surgical technique in patients with lumbar spinal stenosis. Primary outcome measures were pain, disability, recovery and quality of life. The PEDro scale was used for risk of bias assessment. Data were pooled with a random-effects model, and the GRADE approach was used to summarise conclusions. Results Nineteen published reports (17 trials) were included. No trials were identified comparing surgery to no treatment or placebo/sham. Pooling revealed that decompression plus fusion is not superior to decompression alone for pain (mean difference –3.7, 95% confidence interval –15.6 to 8.1), disability (mean difference 9.8, 95% confidence interval –9.4 to 28.9), or walking ability (risk ratio 0.9, 95% confidence interval 0.4 to 1.9). Interspinous process spacer devices are slightly more effective than decompression plus fusion for disability (mean difference 5.7, 95% confidence interval 1.3 to 10.0), but they resulted in significantly higher reoperation rates when compared to decompression alone (28% v 7%, P < 0.001). There are no differences in the effectiveness between other surgical techniques for our main outcomes. Conclusions The relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.
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Affiliation(s)
- Gustavo C. Machado
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- * E-mail:
| | - Paulo H. Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Ian A. Harris
- South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, University of New South Wales, Sydney, NSW, Australia
| | - Marina B. Pinheiro
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Bart W. Koes
- Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Maurits van Tulder
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Magdalena Rzewuska
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Chris G. Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Manuela L. Ferreira
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Institute of Bone and Joint Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. Spine J 2015; 15:348-62. [PMID: 25463400 DOI: 10.1016/j.spinee.2014.10.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 08/01/2014] [Accepted: 10/07/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Low back pain is debilitating and costly, especially for patients not responding to conservative therapy and requiring surgery. PURPOSE Our objective was to determine whether epidural steroid injections (ESI) have a surgery-sparing effect in patients with spinal pain. STUDY DESIGN/SETTING The study design was based on a systematic review and meta-analysis. METHODS Databases searched included Cochrane, PubMed, and EMBASE. The primary analysis evaluated randomized controlled trials (RCTs) in which treatment groups received ESI and control groups underwent control injections. Secondary analyses involved RCTs comparing surgery with ESI, and subgroup analyses of trials comparing surgery with conservative treatment in which the operative disposition of subjects who received ESI were evaluated. RESULTS Of the 26 total studies included, only those evaluating the effect of ESI on the need for surgery as a primary outcome examined the same patient cohort, providing moderate evidence that patients who received ESI were less likely to undergo surgery than those who received control treatment. For studies examining surgery as a secondary outcome, ESI demonstrated a trend to reduce the need for surgery for short-term (<1 year) outcomes (risk ratio, 0.68; 95% confidence interval, 0.41-1.13; p=.14) but not long-term (≥1 year) outcomes (0.95, 0.77-1.19, p=.68). Secondary analyses provided low-level evidence suggesting that between one-third and half of patients considering surgery who undergo ESI can avoid surgery. CONCLUSIONS Epidural steroid injections may provide a small surgery-sparing effect in the short term compared with control injections and reduce the need for surgery in some patients who would otherwise proceed to surgery.
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Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: a retrospective study. J Manipulative Physiol Ther 2015; 38:188-94. [PMID: 25620608 DOI: 10.1016/j.jmpt.2014.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this preliminary study was to assess the effectiveness of a 6-week, nonsurgical, multimodal program that addresses the multifaceted aspects of neurogenic claudication. METHODS In this retrospective study, 2 researchers independently extracted data from the medical records from January 2010 to April 2013 of consecutive eligible patients who had completed the 6-week Boot Camp Program. The program consisted of manual therapy twice per week (eg, soft tissue and neural mobilization, chiropractic spinal manipulation, lumbar flexion-distraction, and muscle stretching), structured home-based exercises, and instruction of self-management strategies. A paired t test was used to compare differences in outcomes from baseline to 6-week follow-up. Outcomes included self-reported pain, disability, walking ability, and treatment satisfaction. RESULTS A total of 49 patients were enrolled, with a mean age of 70 years. The mean difference in the Oswestry Disability Index was 15.2 (95% confidence interval [CI], 11.39-18.92), and that for the functional and symptoms scales of the Swiss Spinal Stenosis Questionnaire was 0.41 (95% CI, 0.26-0.56) and 0.74 (95% CI, 0.55-0.93), respectively. Numeric pain scores for both leg and back showed statistically significant improvements. Improvements in all outcomes were clinically important. CONCLUSIONS This study showed preliminary evidence for improved outcomes in patients with neurogenic claudication participating in a 6-week nonsurgical multimodal Boot Camp Program.
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Giraldo-Prieto M. Axonal, bladder and bowel impairment: evidence based clinical review of gaps in guidelines for spinal stenosis. REVISTA COLOMBIANA DE MÉDICINA FÍSICA Y REHABILITACIÓN 2015; 25:53-62. [DOI: 10.28957/rcmfr.v25n1a6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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30
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Sigmundsson FG. Determinants of outcome in lumbar spinal stenosis surgery. ACTA ORTHOPAEDICA. SUPPLEMENTUM 2014; 85:1-45. [PMID: 25491267 DOI: 10.3109/17453674.2014.976807] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Park CK, Kim SB, Kim MK, Park BJ, Choi SG, Lim YJ, Kim TS. Comparison of treatment methods in lumbar spinal stenosis for geriatric patient: nerve block versus radiofrequency neurotomy versus spinal surgery. KOREAN JOURNAL OF SPINE 2014; 11:97-102. [PMID: 25346752 PMCID: PMC4206970 DOI: 10.14245/kjs.2014.11.3.97] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/15/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The incidence of spinal treatment, including nerve block, radiofrequency neurotomy, instrumented fusions, is increasing, and progressively involves patients of age 65 and older. Treatment of the geriatric patients is often a difficult challenge for the spine surgeon. General health, sociofamilial and mental condition of the patients as well as the treatment techniques and postoperative management are to be accurately evaluated and planned. We tried to compare three treatment methods of spinal stenosis for geriatric patient in single institution. METHODS The cases of treatment methods in spinal stenosis over than 65 years old were analyzed. The numbers of patients were 371 underwent nerve block, radiofrequency neurotomy, instrumented fusions from January 2009 to December 2012 (nerve block: 253, radiofrequency neurotomy: 56, instrumented fusions: 62). The authors reviewed medical records, operative findings and postoperative clinical results, retrospectively. Simple X-ray were evaluated and clinical outcome was measured by Odom's criteria at 1 month after procedures. RESULTS We were observed excellent and good results in 162 (64%) patients with nerve block, 40 (71%) patient with radIofrequency neurotomy, 46 (74%) patient with spinal surgery. Poor results were 20 (8%) patients in nerve block, 2 (3%) patients in radiofrequency neurotomy, 3 (5%) patient in spinal surgery. CONCLUSION We reviewed literatures and analyzed three treatment methods of spinal stenosis for geriatric patients. Although the long term outcome of surgical treatment was most favorable, radiofrequency neurotomy and nerve block can be considered for the secondary management of elderly lumbar spinals stenosis patients.
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Affiliation(s)
- Chang Kyu Park
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sung Bum Kim
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Min Ki Kim
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Bong Jin Park
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seok Geun Choi
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Young Jin Lim
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Sung Kim
- Department of Neurosurgery, Kyung Hee University College of Medicine, Seoul, Korea
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Leem JG. Epidural steroid injection: a need for a new clinical practice guideline. Korean J Pain 2014; 27:197-9. [PMID: 25031804 PMCID: PMC4099231 DOI: 10.3344/kjp.2014.27.3.197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jeong Gill Leem
- Deptartment of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
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What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1282-301. [PMID: 24633719 DOI: 10.1007/s00586-014-3262-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate what interventions can improve walking ability in neurogenic claudication with lumbar spinal stenosis. METHODS We searched CENTRAL, Medline, EMBASE, CINAHL and ICL databases up to June 2012. Only randomized controlled trials published in English and measuring walking ability were included. Data extraction, risk of bias assessment, and quality of the evidence evaluation were performed using methods of the Cochrane Back Review Group. RESULTS We accepted 18 studies with 1,220 participants. There is very low quality evidence that calcitonin is no better than placebo or paracetamol regardless of mode of administration. There is low quality evidence that prostaglandins, and very low quality evidence that gabapentin or methylcobalamin, improves walking distance. There is low and very low quality evidence that physical therapy was no better in improving walking ability compared to no treatment, oral diclofenac plus home exercises, or combined manual therapy and exercise. There is very low quality evidence that epidural injections improve walking distance up to 2 weeks compared to placebo. There is low- and very low-quality evidence that various direct decompression surgical techniques show similar significant improvements in walking ability. There is low quality evidence that direct decompression is no better than non-operative treatment in improving walking ability. There is very low quality evidence that indirect decompression improves walking ability compared to non-operative treatment. CONCLUSIONS Current evidence for surgical and non-surgical treatment to improve walking ability is of low and very low quality and thus prohibits recommendations to guide clinical practice.
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Abstract
We aimed to evaluate the available evidence on the effectiveness of surgical interventions for a number of conditions resulting in low back pain (LBP) or spine-related irradiating leg pain. We searched the Cochrane databases and PubMed up to June 2013. We included systematic reviews and randomised controlled trials (RCTs) on degenerative disc disease (DDD), herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons between surgery and conservative care and between different techniques. The quality of the systematic reviews was evaluated using assessment of multiple systematic reviews (AMSTAR). Twenty systematic reviews were included which covered the following diagnoses: disc herniation (n = 9), spondylolisthesis (n = 2), spinal stenosis (n = 3), DDD (n = 4) and combinations (n = 2). For most of the comparisons, no significant and/or clinically relevant differences between interventions were identified. In general, surgery is only indicated for relief of leg pain in clear indications such as disc herniation, spondylolisthesis or spinal stenosis.
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