The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot

The Dietary Intake of Polyphenols Is Associated with a Lower Risk of Severe Lumbar Spinal Stenosis: A Case-Control Analysis from the PREFACE Study

Polyphenols are naturally occurring compounds endowed with antioxidant and anti-inflammatory properties. We sought to examine the association of dietary polyphenols with the risk of severe lumbar spinal stenosis (LSS), a condition possibly characterized by a high inflammatory component. A case-control study included 156 patients with LSS and indication to surgery and 312 controls, matched (1:2) for sex, age (±6 months), and physical activity. The polyphenol intake was calculated by matching food consumption data from a 188-item food frequency questionnaire with the Phenol-Explorer database regarding the polyphenol content of each reported food. In a multivariable-adjusted logistic regression analysis including lifestyles, sociodemographic factors, and the Mediterranean Diet Score, a 1-standard deviation (SD) increase in dietary polyphenols intake was associated with lower odds of LSS (Odds ratio [OR] = 0.65; 95% CI: 0.47-0.89). Analyses of different polyphenol classes showed that a per 1-SD in the consumption of flavonoids and stilbenes was related to lower LSS risk (OR = 0.57; 95% CI: 0.42-0.78; OR = 0.40; 95% CI: 0.27-0.61, respectively). Further adjustment for the total dietary antioxidant capacity did not modify the strength of these associations. A diet rich in polyphenols is independently associated with a lower risk of severe LSS, possibly through mechanisms that include the anti-inflammatory potential of these bioactive compounds.

Step Count in Patients With Lumbar Spinal Stenosis: Accuracy During Walking and Nonwalking Activities

STUDY DESIGN

This is a method development and validation study.

OBJECTIVES

The purpose of this study was to develop and test a method for step detection using accelerometer data in patients with lumbar spinal stenosis (LSS). There are 2 objectives: (1) to describe a method for step detection from accelerations measured at the wrist, hip, lower back, thigh and ankle; (2) to assess the accuracy of the method during walking with and without walking aids and during nonwalking activities.

SUMMARY OF BACKGROUND DATA

Loss of walking ability is one of the main symptoms of LSS, and there is no validated measure to assess walking activity in daily living in patients with LSS.

MATERIALS AND METHODS

Thirty patients with LSS performed a standardized movement protocol that included walking with and without walking aids and performing nonwalking activities while wearing accelerometers on five different wear-sites. After the walking tests, a method was designed for optimal step detection and compared with a gold standard of observed step count.

RESULTS

The method for step detection applied to accelerations from the lower back, hip, thigh, and ankle provided an accurate step counts during continuous walking without walking aids. Accuracy diminished at all wear-sites when walking with walking aids, except the ankle. The wrist provided the most inaccurate step count, and the accelerometers on the thigh and ankle were prone to falsely detecting steps during bicycling.

CONCLUSION

The ankle-worn accelerometer provided the most accurate step count, but wrongly registered steps during nonwalking activities. The developed step detection method shows potential as a measure of walking activity why further development and testing under free-living conditions should be performed.

Pre-operative prognostic factors for walking capacity after surgery for lumbar spinal stenosis: a systematic review

BACKGROUND

Lumbar spinal stenosis (LSS) reduces walking and quality of life. It is the main indication for spinal surgery in older people yet 40% report walking disability post-operatively. Identifying the prognostic factors of post-operative walking capacity could aid clinical decision-making, guide rehabilitation and optimise health outcomes.

OBJECTIVE

To synthesise the evidence for pre-operative mutable and immutable prognostic factors for post-operative walking in adults with LSS.

DESIGN

Systematic review with narrative synthesis.

METHODS

Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, OpenGrey) were searched for observational studies, evaluating factors associated with walking after surgery in adults receiving surgery for LSS from database inception to January 2020. Two reviewers independently evaluated studies for eligibility, extracted data and assessed risk of bias (Quality in Prognosis Studies). The Grading of Recommendations Assessment, Development and Evaluation method was used to determine level of evidence for each factor.

RESULTS

5526 studies were screened for eligibility. Thirty-four studies (20 cohorts, 9,973 participants, 26 high, 2 moderate, 6 low risk of bias) were included. Forty variables (12 mutable) were identified. There was moderate quality of evidence that pre-operative walking capacity was positively associated with post-operative walking capacity. The presence of spondylolisthesis and the severity of stenosis were not associated with post-operative walking capacity. All other factors investigated had low/very low level of evidence.

CONCLUSION

Greater pre-operative walking is associated with greater post-operative walking capacity but not spondylolisthesis or severity of stenosis. Few studies have investigated mutable prognostic factors that could be potentially targeted to optimise surgical outcomes.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

New Factor Structure of the Tampa Scale for Kinesiophobia in Older Japanese Adults After Lumbar Surgery

Purpose

The Tampa Scale for Kinesiophobia (TSK) has been used worldwide as a measure of kinesiophobia, but its factor structure in older Japanese adults after lumbar surgery is unknown. The purpose of this study was to fill this research gap by identifying the factors that comprise TSK in older Japanese adults after lumbar surgery.

Patients and Methods

Participants were older Japanese adults who had undergone surgery for lumbar spinal stenosis. Clinicodemographic data, TSK, intensity of low back pain and leg pain, dysesthesia (using an 11-point numerical rating scale), and HRQOL (using the EQ-5D-5L) were collected. After supplementing the missing values by the multiple assignment method, the hypothetical model of TSK was developed by categorical exploratory factor analysis (weighted least squares method, promax rotation). Confirmatory factor analysis (WLSMV method, promax rotation) was used to compare the hypothetical model and the traditional one-factor and two-factor models. Furthermore, we confirmed the relationship between factors extracted from the hypothetical model and HRQOL, pain, and dysesthesia.

Results

Questionnaires were mailed to 302 individuals, and responses were obtained from 211 (72.4±4.2 years [range: 65–88]; 115 men and 96 women; 804±343.1 [380–1531] days after surgery; 137 who had undergone decompression and fixation surgery, 74 who had undergone decompression surgery) (response rate: 69.9%). The hypothesized model consisted of “somatic focus,” “activity avoidance,” and “efficacy of physical activities,” all of which were highly consistent. The fit of the hypothetical model was slightly inferior to that of the traditional two-factor model, but the hypothetical model met the criteria for fit. Somatic focus in the hypothetical model was significantly associated with HRQOL, pain, and dysesthesia.

Conclusion

In older Japanese adults after lumbar surgery, the goodness of fit of the TSK model was maintained by adding efficacy of physical activities as a third factor to the traditional two factors.

An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach

OBJECTIVE

Lumbar spinal stenosis (LSS) can lead to compression of the neural and vascular elements and is becoming more common due to degenerative changes that occur because of aging processes. Symptoms may manifest as pain and discomfort that radiates to the lower leg, thigh, and/or buttocks. The traditional treatment algorithm for LSS consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered. In this review, the variables that should be considered during the management of patients with LSS are discussed, and the role of each treatment option to provide optimal care is evaluated.

RESULTS

This review leads to the creation of an evidence-based practical algorithm to aid clinicians in the management of patients with LSS. Special emphasis is directed at minimally invasive surgery, which should be taken into consideration when conservative management and ESI have failed.

Digital Care for Chronic Musculoskeletal Pain: 10,000 Participant Longitudinal Cohort Study

BACKGROUND

Chronic musculoskeletal pain has a vast global prevalence and economic burden. Conservative therapies are universally recommended but require patient engagement and self-management to be effective.

OBJECTIVE

This study aimed to evaluate the efficacy of a 12-week digital care program (DCP) in a large population of patients with chronic knee and back pain.

METHODS

A longitudinal observational study was conducted using a remote DCP available through a mobile app. Subjects participated in a 12-week multimodal DCP incorporating education, sensor-guided exercise therapy (ET), and behavioral health support with 1-on-1 remote health coaching. The primary outcome was pain measured by the visual analog scale (VAS). Secondary measures included engagement levels, program completion, program satisfaction, condition-specific pain measures, depression, anxiety, and work productivity.

RESULTS

A total of 10,264 adults with either knee (n=3796) or low back (n=6468) pain for at least three months were included in the study. Participants experienced a 68.45% average improvement in VAS pain between baseline intake and 12 weeks. In all, 73.04% (7497/10,264) participants completed the DCP into the final month. In total, 78.60% (5893/7497) of program completers (7144/10,264, 69.60% of all participants) achieved minimally important change in pain. Furthermore, the number of ET sessions and coaching interactions were both positively associated with improvement in pain, suggesting that the amount of engagement influenced outcomes. Secondary outcomes included a 57.9% and 58.3% decrease in depression and anxiety scores, respectively, and 61.5% improvement in work productivity. Finally, 3 distinct clusters of pain response trajectories were identified, which could be predicted with a mean 76% accuracy using baseline measures.

CONCLUSIONS

These results support the efficacy and scalability of a DCP for chronic low back and knee pain in a large, diverse, real-world population. Participants demonstrated high completion and engagement rates and a significant positive relationship between engagement and pain reduction was identified, a finding that has not been previously demonstrated in a DCP. Furthermore, the large sample size allowed for the identification of distinct pain response subgroups, which may prove beneficial in predicting recovery and tailoring future interventions. This is the first longitudinal digital health study to analyze pain outcomes in a sample of this magnitude, and it supports the prospect for DCPs to serve the overwhelming number of musculoskeletal pain sufferers worldwide.

Objective activity tracking in spine surgery: a prospective feasibility study with a low-cost consumer grade wearable accelerometer

Patient-reported outcome measures (PROMs) are commonly used to estimate disability of patients with spinal degenerative disease. Emerging technological advances present an opportunity to provide objective measurements of activity. In a prospective, observational study we utilized a low-cost consumer grade wearable accelerometer (LCA) to determine patient activity (steps per day) preoperatively (baseline) and up to one year (Y1) after cervical and lumbar spine surgery. We studied 30 patients (46.7% male; mean age 57 years; 70% Caucasian) with a baseline activity level of 5624 steps per day. The activity level decreased by 71% in the 1^st postoperative week (p < 0.001) and remained 37% lower in the 2^nd (p < 0.001) and 23% lower in the 4^th week (p = 0.015). At no time point until Y1 did patients increase their activity level, compared to baseline. Activity was greater in patients with cervical, as compared to patients with lumbar spine disease. Age, sex, ethnic group, anesthesia risk score and fusion were variables associated with activity. There was no correlation between activity and PROMs, but a strong correlation with depression. Determining activity using LCAs provides real-time and longitudinal information about patient mobility and return of function. Recovery took place over the first eight postoperative weeks, with subtle improvement afterwards.

Supervised physical therapy vs. home exercise for patients with lumbar spinal stenosis: a randomized controlled trial

BACKGROUND CONTEXT

Exercise has been reported to improve short-term outcomes for patients with LSS in terms of disability and back and leg pain. However, no studies have compared supervised exercise with unsupervised exercise or quantified physical activity using a pedometer to confirm compliance with a home exercise program.

PURPOSE

To compare the effectiveness of supervised physical therapy (PT) with unsupervised exercise for patients with lumbar spinal stenosis (LSS).

STUDY DESIGN/SETTING

A single-center, open-label, randomized controlled trial.

PATIENT SAMPLE

Patients presenting with symptoms of neurogenic claudication caused by LSS, which was confirmed by magnetic resonance imaging.

OUTCOME MEASURES

The primary outcome was improvement in symptom severity scores on the Zurich Claudication Questionnaire (ZCQ) at 6 weeks. Secondary outcomes included physical function on the ZCQ, self-paced walking test (SPWT) performance, pain indicated using a numerical rating scale (NRS), and the number of daily steps measured by pedometer.

METHODS

Patients with LSS were randomized to a PT group, who performed supervised PT twice a week for 6 weeks, or a home exercise (HE) group. PT sessions included manual therapy, individually tailored stretching and strengthening exercises, cycling, and body weight-supported treadmill walking.

RESULTS

Forty-three patients were randomly allocated to the PT group and 43 patients to the HE group. Compared with the HE group, the PT group had greater percentage of responders achieving minimum clinically important difference in ZCQ symptom severity (difference for percentage between groups [95%confidence interval], 30.2% [9.1-48.6], p=.01), ZCQ physical function (32.6% [11.6-50.6], p<.01), walking distance on the SPWT (39.5% [18.8-56.7], p<.01), leg pain on the NRS (34.9% [13.9-52.7], p<.01), and number of daily steps (25.6% [4.9-43.9], p=.01).

CONCLUSIONS

Supervised PT for patients with LSS resulted in significant short-term improvements in symptom severity, physical function, walking distance, pain, and physical activity compared with unsupervised exercise.

Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature

BACKGROUND CONTEXT

The accurate determination of a patient's functional status is necessary for therapeutic decision-making and to critically appraise treatment efficacy. Current subjective patient-reported outcome measure (PROM)-based assessments have limitations and can be complimented by objective measures of function.

PURPOSE

To systematically review the literature and provide an overview on the available objective measures of function for patients with degenerative diseases of the lumbar spine.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two reviewers independently searched the PubMed, Web of Science, EMBASE, and SCOPUS databases for permutations of the words "objective," "assessment," "function," "lumbar," and "spine" including articles on human subjects with degenerative diseases of the lumbar spine that reported on objective measures of function, published until September 2018. Risk of bias was not assessed. No funding was received. The authors report no conflicts of interest.

RESULTS

Of 2,389 identified articles, 82 were included in the final analysis. There was a significant increase of 0.12 per year in the number of publications dealing with objective measures of function since 1989 (95% CI 0.08-0.16, p<.001). Some publications studied multiple diagnoses and objective measures. The United States was the leading nation in terms of scientific output for objective outcome measures (n=21; 25.6%), followed by Switzerland (n=17; 20.7%), Canada, Germany, and the United Kingdom (each n=6; 7.3%). Our search revealed 21 different types of objective measures, predominantly applied to patients with lumbar spinal stenosis (n=67 publications; 81.7%), chronic/unspecific low back pain (n=28; 34.2%) and lumbar disc herniation (n=22; 26.8%). The Timed-Up-and-Go test was the most frequently applied measure (n=26 publications; 31.7%; cumulative number of reported subjects: 5,181), followed by the Motorized Treadmill Test (n=25 publications; 30.5%, 1,499 subjects) and with each n=9 publications (11.0%) the Five-Repetition Sit-To-Stand test (955 subjects), as well as accelerometry analyses (336 subjects). The reliability and validity of many of the less-applied objective measures was uncertain. There was profound heterogeneity in their application and interpretation of results.

CONCLUSIONS

Clinical studies on patients with lumbar degenerative diseases increasingly employ objective measures of function, which offer high potential for improving the quality of outcome measurement in patient-care and research. This review provides an overview on available options. Our findings call for an agreement and standardization in terms of test selection, conduction and analysis to facilitate comparison of results across cohorts.

PROSPERO REGISTRATION NUMBER

CRD42019122622.

Digital biomarkers of spine and musculoskeletal disease from accelerometers: Defining phenotypes of free-living physical activity in knee osteoarthritis and lumbar spinal stenosis

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) and knee osteoarthritis (OA) are 2 of the leading causes of disability worldwide. In order to provide disease-specific prescriptions for physical activity, there is a clear need to better understand physical activity in daily life (performance) in these populations.

PURPOSE

To discover performance phenotypes for LSS and OA by applying novel analytical methods to accelerometry data. Specific objectives include the following: (1) to identify characteristic features (phenotypes) of free-living physical activity unique to individuals with LSS and OA, and (2) to determine which features can best differentiate between these conditions.

STUDY DESIGN AND SETTING

Leveraging data from 3 existing cross-sectional cohorts, accelerometry signal feature characterization and selection were performed in a computational laboratory.

PATIENT SAMPLE

Data from a total of 4,028 individuals were analyzed from the following 3 datasets: LSS Accelerometry Database (n=75); OA Initiative (n=1950); and the 2003 to 2004 National Health and Nutrition Examination Survey (pain-free controls, n=2003).

METHODS

In order to characterize the accelerometry signals, data were examined using (1) standard intervals for counts/minute from Freedson et al. and (2) the physical performance intervals for mobility-limited pain populations. From this, 42 novel accelerometry features were defined and evaluated for significance in discriminating between the groups (LSS, OA, and controls) in order to then determine which sparse set of features best differentiates between the groups. These sparse sets of features defined the performance phenotypes.

OUTCOME MEASURES

Accelerometry features and their ability to differentiate between individuals with LSS, OA, and controls.

RESULTS

Given age and gender, classification rates were at least 80% accurate (pairwise) between diseased and pain-free populations (LSS vs. controls and OA vs. controls). The most important features to distinguish between disease groups corresponded to measures in the light and sedentary activity intervals. The more subtle classification between diseased populations (LSS vs. OA) was 72% accurate, with light and moderate activity providing the prominent distinguishing features.

CONCLUSIONS

We describe the discovery of performance phenotypes of LSS and OA from accelerometry data, revealed through a novel set of features that characterize daily patterns of movement in people with LSS and OA. These performance phenotypes provide a new method for analyzing free-living physical activity (performance) in LSS and OA, and provide the groundwork for more personalized approaches to measuring and improving function.

A comparative study of 2-year follow-up outcomes in lumbar spinal stenosis patients treated with physical therapy alone and those with surgical intervention after less successful physical therapy

BACKGROUND

The efficacy of physical therapy for patients with lumbar spinal stenosis (LSS) has been reported only for the short term, and few reports have compared outcomes of surgical treatment with nonsurgical treatment after physical therapy. The purpose of this study was to assess 2-year outcomes of LSS patients treated with surgery or under follow-up observation after physical therapy for 6 weeks.

METHODS

Patients presenting with neurogenic claudication, radiologically-confirmed central LSS affecting both legs and refractory symptoms to pharmacotherapy of more than 3 months were enrolled. Patients were treated with manual therapy, stretching and strengthening exercises, and body weight-supported treadmill walking once a week for 6 weeks. Clinical outcomes were measured using the Zurich Claudication Questionnaire (ZCQ), visual analog scale of low back pain, leg pain, and numbness, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire and the SF-36. Two years after physical therapy, patients were classified into the observation group (Group I) or the surgery group (Group II), whose patients failed to respond to physical therapy and wanted to undergo surgery.

RESULTS

Thirty-eight patients were enrolled; 28 had complete data at 2 years: 21 and 7 in Groups I and II, respectively. Group II had a higher body mass index (BMI) than Group I. There were no significant differences in clinical outcomes at baseline. Six weeks after physical therapy, Group I had significantly better outcomes for symptom severity and physical function on the ZCQ subscales, physical functioning and bodily pain on the SF-36 subscales. These outcomes in Group I were maintained or improved and did not differ significantly between groups at 2-years. However, the physical function on the ZCQ subscales was improved in Group II more than those in Group I (mean difference -0.6; 95% CI: -1.2 to -0.03, P < 0.05) at 2 years.

CONCLUSIONS

At 2 years, the outcomes except for the change in physical function score in the ZCQ subscale did not differ significantly between patients who had undergone surgery and those who avoided surgery.

Objective measurement of function following lumbar spinal stenosis decompression reveals improved functional capacity with stagnant real-life physical activity

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) is a prevalent and costly condition associated with significant dysfunction. Alleviation of pain and improvement of function are the primary goals of surgical intervention. Although prior studies have measured subjective improvements in function after surgery, few have examined objective markers of functional improvement.

PURPOSE

We aimed to objectively measure and quantify changes in physical capacity and physical performance following surgical decompression of LSS.

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

Thirty-eight patients with LSS determined by the treating surgeon's clinical and imaging evaluation, and who were scheduled for surgical treatment, were consecutively recruited at two academic medical facilities, with 28 providing valid data for analysis at baseline and 6 months after surgery.

OUTCOME MEASURES

Before surgery and at 6 months after surgery, participants provided 7 days of real-life physical activity (performance) using ActiGraph accelerometers; completed two objective functional capacity measures, the Short Physical Performance Battery and Self-Paced Walking Test; and completed three subjective functional outcome questionnaires, Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36.

METHODS

Physical activity, as measured by continuous activity monitoring, was analyzed as previously described according to the 2008 American Physical Activity Guidelines. Paired t tests were performed to assess for postsurgical changes in all questionnaire outcomes and all objective functional capacity measures. Chi-square analysis was used to categorically assess whether patients were more likely to meet these physical activity recommendations after surgery.

RESULTS

Participants were 70.1 years old (±8.9) with 17 females (60.7%) and an average body mass index of 28.4 (±6.2). All subjective measures (Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36) improved significantly at 6 months after surgery, as did objective functional measures of capacity including balance, gait speed, and ambulation distance (Short Physical Performance Battery, Self-Paced Walking Test). However, objectively measured performance (real-life physical activity) did not change following surgery. Although fewer participants qualified as inactive (54% vs. 71%), and more (11% vs. 4%) met the physical activity guideline recommendations at the 6-month follow-up, these differences were not statistically significant (p=.22) CONCLUSIONS: This is the first study, of which we are aware, to objectively evaluate changes in postsurgical performance (real-life physical activity) in people with LSS. We found that at 6 months after surgery for LSS, participants demonstrated significant improvements in self-reported function and objectively measured physical capacity, but not physical performance as measured by continuous activity monitoring. This lack of improvement in performance, despite improvements in self-reported function and objective capacity, suggests a role for postoperative rehabilitation focused specifically on increasing performance after surgery in the LSS population.

Key Components in eHealth Interventions Combining Self-Tracking and Persuasive eCoaching to Promote a Healthier Lifestyle: A Scoping Review

BACKGROUND

The combination of self-tracking and persuasive eCoaching in automated interventions is a new and promising approach for healthy lifestyle management.

OBJECTIVE

The aim of this study was to identify key components of self-tracking and persuasive eCoaching in automated healthy lifestyle interventions that contribute to their effectiveness on health outcomes, usability, and adherence. A secondary aim was to identify the way in which these key components should be designed to contribute to improved health outcomes, usability, and adherence.

METHODS

The scoping review methodology proposed by Arskey and O'Malley was applied. Scopus, EMBASE, PsycINFO, and PubMed were searched for publications dated from January 1, 2013 to January 31, 2016 that included (1) self-tracking, (2) persuasive eCoaching, and (3) healthy lifestyle intervention.

RESULTS

The search resulted in 32 publications, 17 of which provided results regarding the effect on health outcomes, 27 of which provided results regarding usability, and 13 of which provided results regarding adherence. Among the 32 publications, 27 described an intervention. The most commonly applied persuasive eCoaching components in the described interventions were personalization (n=24), suggestion (n=19), goal-setting (n=17), simulation (n=17), and reminders (n=15). As for self-tracking components, most interventions utilized an accelerometer to measure steps (n=11). Furthermore, the medium through which the user could access the intervention was usually a mobile phone (n=10). The following key components and their specific design seem to influence both health outcomes and usability in a positive way: reduction by setting short-term goals to eventually reach long-term goals, personalization of goals, praise messages, reminders to input self-tracking data into the technology, use of validity-tested devices, integration of self-tracking and persuasive eCoaching, and provision of face-to-face instructions during implementation. In addition, health outcomes or usability were not negatively affected when more effort was requested from participants to input data into the technology. The data extracted from the included publications provided limited ability to identify key components for adherence. However, one key component was identified for both usability and adherence, namely the provision of personalized content.

CONCLUSIONS

This scoping review provides a first overview of the key components in automated healthy lifestyle interventions combining self-tracking and persuasive eCoaching that can be utilized during the development of such interventions. Future studies should focus on the identification of key components for effects on adherence, as adherence is a prerequisite for an intervention to be effective.

Minimum Clinically Important Difference: Current Trends in the Spine Literature

STUDY DESIGN

Review of the 2011 to 2015 minimum clinically important difference (MCID)-related publications in Spine, Spine Journal, Journal of Neurosurgery-Spine, and European Spine Journal.

OBJECTIVE

To summarize the various determinations of MCID and to analyze its usage in the spine literature of the past 5 years in order to develop a basic reference to help practitioners interpret or utilize MCID.

SUMMARY OF BACKGROUND DATA

MCID represents the smallest change in a domain of interest that is considered beneficial to a patient or clinician. The many sources of variation in calculated MCID values and inconsistency in its utilization have resulted in confusion in the interpretation and use of MCID.

METHODS

All articles from 2011 to 2015 were reviewed. Only clinical science articles utilizing patient reported outcome scores (PROs) were included in the analysis. A keyword search was then performed to identify articles that used MCID. MCID utilization in the selected papers was characterized and recorded.

RESULTS

MCID was referenced in 264/1591 (16.6%) clinical science articles that utilized PROs: 22/264 (8.3%) independently calculated MCID values and 156/264 (59.1%) used previously published MCID values as a gauge of their own results. Despite similar calculation methods, there was a two- or three-fold range in the recommended MCID values for the same instrument. Half the studies recommended MCID values within the measurement error. Most studies (97.2%) using MCID to evaluate their own results relied on generic MCID. The few studies using specific MCID (MCID calculated for narrowly defined indications or treatments) did not consistently match the characteristics of their sample to the specificity of the MCID. About 48% of the studies compared group averages instead of individual scores to the MCID threshold.

CONCLUSION

Despite a clear interest in MCID as a measure of patient improvement, its current developments and uses have been inconsistent.

LEVEL OF EVIDENCE

N/A.

Effectiveness of surgery versus conservative treatment for lumbar spinal stenosis: A system review and meta-analysis of randomized controlled trials

PURPOSE

Lumbar spinal stenosis (LSS) was a common degenerative disease that affected the lumbar spine function and quality of life, which can be treated both surgery and conservative treatment. We did this study to compare the effectiveness of surgery versus conservative treatment for LSS.

METHODS

We searched PubMed as well as other databases in September.18th.2016. Randomized controlled trials compared surgery versus conservative treatment for patients with LSS were enrolled. Outcomes and complications were collected with data selection criteria and analyzed with Review Manager Version 5.3.

RESULTS

Nine RCTs (14 articles) and 1658 patients were included, and three of them were high-quality studies. At first 6 months after treatment, there were no significant differences for ODI scores between two therapeutic groups (P > 0.05), however, surgery group showed significant higher ODI scores at one year (P < 0.05) and two years (P < 0.05). Two studies reported no significant difference between laminectomy and conservative treatment for the SF-36 physical function scores at 3 months, 6 months, 12 months and 24 months (P > 0.05) and two studies reported patients were satisfied with X-STOP implanted at six weeks, six months, and one year. No statistical differences for the adverse events intra-operation or within 72 h (P > 0.05) between surgery and non-surgery groups. Moreover, subgroup analysis showed there were no safety differences between laminectomy and conservative treatment, X-STOP and conservative treatment at early stage of duration. However, the surgical groups had higher complication rates than non-surgery groups throughout the follow-up duration.

CONCLUSION

Surgery groups showed better late clinical outcomes after one year and higher complication rate throughout the follow-up duration, although it had no significant differences compared with conservative groups in the first six months post-treatment. However, there was no evidence that a definitive method could be firmly recommended to LSS patients. Further researches were needed to achieve high quality and credible results.

Physical performance analysis: A new approach to assessing free-living physical activity in musculoskeletal pain and mobility-limited populations

Background

Accurate measurement of physical performance in individuals with musculoskeletal pain is essential. Accelerometry is a powerful tool for this purpose, yet the current methods designed to evaluate energy expenditure are not optimized for this population. The goal of this study is to empirically derive a method of accelerometry analysis specifically for musculoskeletal pain populations.

Methods

We extracted data from 6,796 participants in the 2003–4 National Health and Nutrition Examination Survey (NHANES) including: 7-day accelerometry, health and pain questionnaires, and anthropomorphics. Custom macros were used for data processing, complex survey regression analyses, model selection, and statistical adjustment. After controlling for a multitude of variables that influence physical activity, we investigated whether distinct accelerometry profiles accompany pain in different locations of the body; and we identified the intensity intervals that best characterized these profiles.

Results

Unique accelerometry profiles were observed for pain in different body regions, logically clustering together based on proximity. Based on this, the following novel intervals (counts/minute) were identified and defined: Performance Sedentary (PSE) = 1–100, Performance Light 1 (PL1) = 101–350, Performance Light 2 (PL2) = 351–800, Performance Light 3 (PL3) = 801–2500, and Performance Moderate/Vigorous (PMV) = 2501–30000. The refinement of accelerometry signals into these new intervals, including 3 distinct ranges that fit inside the established light activity range, best captures alterations in real-life physical performance as a result of regional pain.

Discussion and conclusions

These new accelerometry intervals provide a model for objective measurement of real-life physical performance in people with pain and musculoskeletal disorders, with many potential uses. They may be used to better evaluate the relationship between pain and daily physical function, monitor musculoskeletal disease progression, gauge disease severity, inform exercise prescription, and quantify the functional impact of treatments. Based on these findings, we recommend that future studies of pain and musculoskeletal disorders analyze accelerometry output based on these new “physical performance” intervals.

Objective measurement of free-living physical activity (performance) in lumbar spinal stenosis: are physical activity guidelines being met?

BACKGROUND

Research suggests that people with lumbar spinal stenosis (LSS) would benefit from increased physical activity. Yet, to date, we do not have disease-specific activity guidelines for LSS, and the nature of free-living physical activity (performance) in LSS remains unknown. LSS care providers could endorse the 2008 United States Physical Activity Guidelines; however, we do not know if this is realistic. The goal of the present study was to determine the proportion of individuals with LSS meeting the 2008 Guidelines. A secondary goal was to better understand the nature of physical performance in this population.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

People from the Lumbar Spinal Stenosis Accelerometry Database, all of whom have both radiographic and clinical LSS and are seeking various treatments for their symptoms.

OUTCOME MEASURES

Seven-day accelerometry (functional outcome) and demographics (self-reported).

METHODS

For the present study, we analyzed only baseline data that were obtained before any new treatments. Patients with at least 4 valid days of baseline accelerometry data were included. We determined the proportion of individuals with LSS meeting the 2008 US Physical Activity Guidelines of at least 150 minutes of moderate-vigorous (MV) physical activity per week in bouts of 10 minutes or more. We also used the novel Physical Performance analysis designed by our group to determine time spent in varying intensities of activity. There are no conflicts of interest to disclose.

RESULTS

We analyzed data from 75 individuals with a mean age of 68 (SD 9), 37% of whom were male. Three people (4%) were considered Meeting Guidelines (at least 150 MV minutes/week), and 56 (75%) were considered Inactive with not even 1 MV minute/week. With the 10-minute bout requirement removed, 10 of 75 (13%) achieved the 150-minute threshold. The average time spent in sedentary activity was 82%, and of time spent in nonsedentary activity, 99.6% was in the light activity range.

CONCLUSIONS

In conclusion, the present study confirms that people with symptomatic LSS, neurogenic claudication, walking limitations, and LSS-related disability are extremely sedentary and are not meeting guidelines for physical activity. There is an urgent need for interventions aimed at reducing sedentary behavior and increasing the overall level of physical activity in LSS, not only to improve function but also to prevent diseases of inactivity. The present study suggests that reducing sedentary time, increasing time spent in light intensity activity, and increasing time spent in higher intensities of light activity may be appropriate as initial goals for exercise interventions in people with symptomatic LSS and neurogenic claudication, transitioning to moderate activity when appropriate. Results of the present study also demonstrate the importance of employing disease-specific measures for assessment of performance in LSS, and highlight the potential value of these methods for developing targeted and realistic goals for physical activity. Physical activity goals could be personalized using objective assessment of performance with accelerometry. The present study is one step toward a personalized medicine approach for people with LSS, focusing on increasing physical function.

Surgical Versus Nonsurgical Treatment for Lumbar Spinal Stenosis

STUDY DESIGN

A systematic review.

OBJECTIVES

The aim of this study is to evaluate the effectiveness of different types of surgery compared with different types of nonsurgical interventions in adults with symptomatic lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

LSS is a debilitating condition associated with degeneration of the spine with aging. People with LSS experience a range of symptoms, including back pain, leg pain, numbness and tingling in the legs, and reduced physical function. Main treatment options are surgery, physical therapy, exercise, braces, and injections into the spine.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases, and two trials registries up to February 2015, reference lists, and conference proceedings related to treatment of the spine. Randomized controlled trials (RCTs) compared surgical versus nonoperative treatments in participants with LSS.Outcomes included quality of life, disability, function, pain, complication rates, and side effects.

RESULTS

From the 12,966 citations screened, we included five RCTs (643 participants).Three studies compared spine surgery versus various types of nonsurgical treatment. It is difficult to draw conclusions from these studies because nonsurgical treatments were inadequately described. One study that compared surgery versus bracing and exercise found no differences in pain. Another study compared surgery versus spinal injections and found better physical function with injections, and better pain relief with surgery at six weeks. Still another trial compared surgery with an implanted device versus nonsurgical care. This study reported favorable outcomes of surgery for symptoms and physical function.

CONCLUSION

We cannot conclude on the basis of this review whether surgical or nonsurgical treatment is better for individuals with LSS. Nevertheless, we can report on the high rate of effects reported in three of five surgical groups, ranging from 10% to 24%. No side effects were reported for any of the conservative treatment options.

LEVEL OF EVIDENCE

1.

Surgical versus non-surgical treatment for lumbar spinal stenosis

BACKGROUND

Lumbar spinal stenosis (LSS) is a debilitating condition associated with degeneration of the spine with aging.

OBJECTIVES

To evaluate the effectiveness of different types of surgery compared with different types of non-surgical interventions in adults with symptomatic LSS. Primary outcomes included quality of life, disability, function and pain. Also, to consider complication rates and side effects, and to evaluate short-, intermediate- and long-term outcomes (six months, six months to two years, five years or longer).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases and two trials registries up to February 2015. We also screened reference lists and conference proceedings related to treatment of the spine.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical versus non-operative treatments in participants with lumbar spinal stenosis confirmed by clinical and imaging findings.

DATA COLLECTION AND ANALYSIS

For data collection and analysis, we followed methods guidelines of the Cochrane Back and Neck Review Group (Furlan 2009) and those provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

MAIN RESULTS

From the 12,966 citations screened, we assessed 26 full-text articles and included five RCTs (643 participants).Low-quality evidence from the meta-analysis performed on two trials using the Oswestry Disability Index (pain-related disability) to compare direct decompression with or without fusion versus multi-modal non-operative care showed no significant differences at six months (mean difference (MD) -3.66, 95% confidence interval (CI) -10.12 to 2.80) and at one year (MD -6.18, 95% CI -15.03 to 2.66). At 24 months, significant differences favoured decompression (MD -4.43, 95% CI -7.91 to -0.96). Low-quality evidence from one small study revealed no difference in pain outcomes between decompression and usual conservative care (bracing and exercise) at three months (risk ratio (RR) 1.38, 95% CI 0.22 to 8.59), four years (RR 7.50, 95% CI 1.00 to 56.48) and 10 years (RR 4.09, 95% CI 0.95 to 17.58).Low-quality evidence from one small study suggested no differences at six weeks in the Oswestry Disability Index for patients treated with minimally invasive mild decompression versus those treated with epidural steroid injections (MD 5.70, 95% CI 0.57 to 10.83; 38 participants). Zurich Claudication Questionnaire (ZCQ) results were better for epidural injection at six weeks (MD -0.60, 95% CI -0.92 to -0.28), and visual analogue scale (VAS) improvements were better in the mild decompression group (MD 2.40, 95% CI 1.92 to 2.88). At 12 weeks, many cross-overs prevented further analysis.Low-quality evidence from a single study including 191 participants favoured the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity and physical function.All remaining studies reported complications associated with surgery and conservative side effects of treatment: Two studies reported no major complications in the surgical group, and the other study reported complications in 10% and 24% of participants, including spinous process fracture, coronary ischaemia, respiratory distress, haematoma, stroke, risk of reoperation and death due to pulmonary oedema.

AUTHORS' CONCLUSIONS

We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.

Management of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

The association between chronic pain and obesity

Obesity and pain present serious public health concerns in our society. Evidence strongly suggests that comorbid obesity is common in chronic pain conditions, and pain complaints are common in obese individuals. In this paper, we review the association between obesity and pain in the general population as well as chronic pain patients. We also review the relationship between obesity and pain response to noxious stimulation in animals and humans. Based upon the existing research, we present several potential mechanisms that may link the two phenomena, including mechanical/structural factors, chemical mediators, depression, sleep, and lifestyle. We discuss the clinical implications of obesity and pain, focusing on the effect of weight loss, both surgical and noninvasive, on pain. The literature suggests that the two conditions are significant comorbidities, adversely impacting each other. The nature of the relationship however is not likely to be direct, but many interacting factors appear to contribute. Weight loss for obese pain patients appears to be an important aspect of overall pain rehabilitation, although more efforts are needed to determine strategies to maintain long-term benefit.