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Peene L, Cohen SP, Kallewaard JW, Wolff A, Huygen F, Gaag AVD, Monique S, Vissers K, Gilligan C, Van Zundert J, Van Boxem K. 1. Lumbosacral radicular pain. Pain Pract 2024; 24:525-552. [PMID: 37985718 DOI: 10.1111/papr.13317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andre Wolff
- Department of Anesthesiology UMCG Pain Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine, Erasmusmc, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antal van de Gaag
- Department of Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steegers Monique
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Chris Gilligan
- Department of Anesthesiology and Pain Medicine, Brigham & Women's Spine Center, Boston, Massachusetts, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Oosterhuis T, Smaardijk VR, Kuijer PPF, Langendam MW, Frings-Dresen MHW, Hoving JL. Systematic review of prognostic factors for work participation in patients with sciatica. Occup Environ Med 2019; 76:772-779. [PMID: 31296665 PMCID: PMC6817989 DOI: 10.1136/oemed-2019-105797] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/28/2019] [Accepted: 06/06/2019] [Indexed: 12/05/2022]
Abstract
Sciatica impacts on the ability to work and may lead to a reduced return to work. This study reviewed and summarised prognostic factors of work participation in patients who received conservative or surgical treatment for clinically diagnosed sciatica. We searched MEDLINE, CINAHL, EMBASE and PsycINFO until January 2018. Cohort studies, using a measure of work participation as outcome, were included. Two independent reviewers performed study inclusion and used the Quality In Prognosis Studies tool for risk of bias assessment and GRADE to rate the quality of the evidence. Based on seven studies describing six cohorts (n=1408 patients) that assessed 21 potential prognostic factors, favourable factors for return to work (follow-up ranging from 3 months to 10 years) included younger age, better general health, less low back pain or sciatica bothersomeness, better physical function, negative straight leg raise-test, physician expecting surgery to be beneficial, better pain coping, less depression and mental stress, less fear of movement and low physical work load. Study results could not be pooled. Using GRADE, the quality of the evidence ranged from moderate to very low, with downgrading mainly for a high risk of bias and imprecision. Several prognostic factors like pain, disability and psychological factors were identified and reviewed, and these could be targeted using additional interventions to optimise return to work. PROSPERO registration number: CRD42016042497.
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Affiliation(s)
- Teddy Oosterhuis
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Veerle R Smaardijk
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - P Paul Fm Kuijer
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Miranda W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Monique H W Frings-Dresen
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jan L Hoving
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Boote J, Newsome R, Reddington M, Cole A, Dimairo M. Physiotherapy for Patients with Sciatica Awaiting Lumbar Micro-discectomy Surgery: A Nested, Qualitative Study of Patients' Views and Experiences. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2017; 22:e1665. [PMID: 26914525 PMCID: PMC5516132 DOI: 10.1002/pri.1665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 06/30/2015] [Accepted: 08/28/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND PURPOSE Sciatica is a common clinical condition that can be extremely painful, disabling and life-changing. Whether conservative or surgical treatment for sciatica secondary to an intervertebral disc prolapse is most effective is still much debated. An important component of conservative treatment is physiotherapy, which aims to promote physical and psychological health for the patient, whilst resorption of the disc takes place. This paper reports a qualitative study of patients' views and experiences of a bespoke physiotherapy intervention for the treatment of sciatica. METHODS A qualitative study nested within a pilot randomized controlled trial of bespoke physiotherapy for the treatment of patients with sciatica awaiting lumbar microdiscectomy surgery. Patients randomized to receive bespoke physiotherapy in the intervention arm of the trial were invited to take part in semi-structured interviews. Twenty-one in-depth, semi-structured interviews took place. All interviews were recorded, fully transcribed and thematically analysed. RESULTS Most patients in the sample found the physiotherapy valuable, appreciating the individual nature of the approach, the exercises to reduce pain and discomfort, techniques for improving functional spinal movement, walking and dynamic posture, and manual therapy and cardiovascular exercise. A small number did not find the physiotherapy of benefit. Sixteen patients in the sample went on to proceed with surgery, but most of these found value in having had the physiotherapy first. DISCUSSION Many patients with sciatica appreciate the value of physiotherapy prior to surgery. Future research should examine patients' experiences of bespoke physiotherapy delivered within primary care. Copyright © 2016 The Authors Physiotherapy Research International published by John Wiley & Sons Ltd.
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Affiliation(s)
- Jonathan Boote
- University of HertfordshireHatfieldUK
- University of SheffieldSheffieldUK
| | - Ruth Newsome
- Sheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | | | - Ashley Cole
- Sheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
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Altun I, Yüksel KZ. Lumbar herniated disc: spontaneous regression. Korean J Pain 2017; 30:44-50. [PMID: 28119770 PMCID: PMC5256262 DOI: 10.3344/kjp.2017.30.1.44] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Low back pain is a frequent condition that results in substantial disability and causes admission of patients to neurosurgery clinics. To evaluate and present the therapeutic outcomes in lumbar disc hernia (LDH) patients treated by means of a conservative approach, consisting of bed rest and medical therapy. METHODS This retrospective cohort was carried out in the neurosurgery departments of hospitals in Kahramanmaraş city and 23 patients diagnosed with LDH at the levels of L3-L4, L4-L5 or L5-S1 were enrolled. RESULTS The average age was 38.4 ± 8.0 and the chief complaint was low back pain and sciatica radiating to one or both lower extremities. Conservative treatment was administered. Neurological examination findings, durations of treatment and intervals until symptomatic recovery were recorded. Laségue tests and neurosensory examination revealed that mild neurological deficits existed in 16 of our patients. Previously, 5 patients had received physiotherapy and 7 patients had been on medical treatment. The number of patients with LDH at the level of L3-L4, L4-L5, and L5-S1 were 1, 13, and 9, respectively. All patients reported that they had benefit from medical treatment and bed rest, and radiologic improvement was observed simultaneously on MRI scans. The average duration until symptomatic recovery and/or regression of LDH symptoms was 13.6 ± 5.4 months (range: 5-22). CONCLUSIONS It should be kept in mind that lumbar disc hernias could regress with medical treatment and rest without surgery, and there should be an awareness that these patients could recover radiologically. This condition must be taken into account during decision making for surgical intervention in LDH patients devoid of indications for emergent surgery.
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Affiliation(s)
- Idiris Altun
- Department of Neurosurgery, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
| | - Kasım Zafer Yüksel
- Department of Neurosurgery, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
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Cost-Effectiveness of Physical Therapy Only and of Usual Care for Various Health Conditions: Systematic Review. Phys Ther 2016; 96:774-86. [PMID: 26678447 DOI: 10.2522/ptj.20140333] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 12/06/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Given continually rising health care costs, interventions of health care providers should be cost-effective. PURPOSE This review aimed to summarize current cost-effectiveness of physical therapy. Specific aims were: (1) to analyze cost-effectiveness of physical therapy only compared with usual care only, (2) to analyze cost-effectiveness of physical therapy added to usual care compared with usual care only, and (3) to specify in which health conditions physical therapy only or physical therapy added to usual care was cost-effective. DATA SOURCES Topic-related systematic reviews were searched in MEDLINE, CINAHL, PEDro, and Cochrane Library and manually. STUDY SELECTION Studies published between 1998 and 2014 that investigated the cost-effectiveness of interventions carried out by physical therapists were reviewed. The methodological quality was assessed with the Cochrane risk of bias assessment for intervention studies and with the Quality of Health Economic Analyses Scale. DATA EXTRACTION Effectiveness and cost data for calculating incremental cost-effectiveness ratios (ICERs) and the original authors' conclusions were extracted. DATA SYNTHESIS The 18 included studies presented low risk of bias and contained 8 comparisons of physical therapy only with usual care only and 11 comparisons of physical therapy added to usual care with usual care only. Based on ICERs, physical therapy only or added to usual care was cost-effective in 9 out of the 19 comparisons and in 10 comparisons according to the original authors' conclusions. CONCLUSION Physical therapy only or added to usual care implies improved health in almost all studies. The cost-effectiveness of such interventions was demonstrated in half of the studies. This result might have been influenced by the fact that different definitions of the notion of "cost-effectiveness" exist.
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Kigozi J, Jowett S, Lewis M, Barton P, Coast J. Estimating productivity costs using the friction cost approach in practice: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:31-44. [PMID: 25387561 DOI: 10.1007/s10198-014-0652-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/28/2014] [Indexed: 05/05/2023]
Abstract
INTRODUCTION The choice of the most appropriate approach to valuing productivity loss has received much debate in the literature. The friction cost approach has been proposed as a more appropriate alternative to the human capital approach when valuing productivity loss, although its application remains limited. This study reviews application of the friction cost approach in health economic studies and examines how its use varies in practice across different country settings. METHODS A systematic review was performed to identify economic evaluation studies that have estimated productivity costs using the friction cost approach and published in English from 1996 to 2013. A standard template was developed and used to extract information from studies meeting the inclusion criteria. RESULTS The search yielded 46 studies from 12 countries. Of these, 28 were from the Netherlands. Thirty-five studies reported the length of friction period used, with only 16 stating explicitly the source of the friction period. Nine studies reported the elasticity correction factor used. The reported friction cost approach methods used to derive productivity costs varied in quality across studies from different countries. CONCLUSIONS Few health economic studies have estimated productivity costs using the friction cost approach. The estimation and reporting of productivity costs using this method appears to differ in quality by country. The review reveals gaps and lack of clarity in reporting of methods for friction cost evaluation. Generating reporting guidelines and country-specific parameters for the friction cost approach is recommended if increased application and accuracy of the method is to be realized.
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Affiliation(s)
- Jesse Kigozi
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Sue Jowett
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Pelham Barton
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Joanna Coast
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, B15 2TT, UK
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Does Kinesiophobia Modify the Effects of Physical Therapy on Outcomes in Patients With Sciatica in Primary Care? Subgroup Analysis From a Randomized Controlled Trial. Phys Ther 2015; 95:1217-23. [PMID: 25929529 DOI: 10.2522/ptj.20140458] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 04/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND A higher level of kinesiophobia appears to be associated with poor recovery in patients with sciatica. OBJECTIVE The aim of this study was to investigate whether kinesiophobia modifies the effect of physical therapy on outcomes in patients with sciatica. DESIGN This was a subgroup analysis from a randomized controlled trial. SETTING The study was conducted in a primary care setting. PATIENTS A total of 135 patients with acute sciatica participated. INTERVENTION Patients were randomly assigned to groups that received (1) physical therapy plus general practitioners' care (intervention group) or (2) general practitioners' care alone (control group). MEASUREMENTS Kinesiophobia at baseline was measured with the Tampa Scale for Kinesiophobia (TSK) and a single substitute question for kinesiophobia (SQK). Pain and recovery were assessed at 3- and 12-month follow-ups. Regression analysis was used to test for interaction between the level of kinesiophobia at baseline and treatment allocation. Subgroup results were calculated for patients classified with high fear of movement and for those classified with low fear of movement. RESULTS Kinesiophobia at baseline interacted with physical therapy in the analysis with leg pain intensity at 12-month follow-up. Kinesiophobia at baseline did not interact with physical therapy regarding any outcome at 3-month follow-up or recovery at 12-month follow-up. When comparing both treatment groups in the subgroup of patients with high fear of movement (n=73), the only significant result was found for leg pain intensity difference from baseline at 12-month follow-up (intervention group: X̅=-5.0, SD=2.6; control group: X̅=-3.6, SD=2.7). LIMITATIONS The post hoc study design and relatively small sample size were limitations of the study. CONCLUSIONS In 135 patients with sciatica, evidence shows that patients with a higher level of kinesiophobia at baseline may particularly benefit from physical therapy with regard to decreasing leg pain intensity at 12-month follow-up.
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Fitzsimmons D, Phillips CJ, Bennett H, Jones M, Williams N, Lewis R, Sutton A, Matar HE, Din N, Burton K, Nafees S, Hendry M, Rickard I, Wilkinson C. Cost-effectiveness of different strategies to manage patients with sciatica. Pain 2014; 155:1318-1327. [DOI: 10.1016/j.pain.2014.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 04/03/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
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Verwoerd AJH, Luijsterburg PAJ, Timman R, Koes BW, Verhagen AP. A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study. J Physiother 2013. [PMID: 23177227 DOI: 10.1016/s1836-9553(12)70126-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
QUESTION In people with sciatica in primary care, can a single question be used to predict outcome at 1 year followup as accurately as validated questionnaires on kinesiophobia, disability, and health-related quality of life? DESIGN Observational study within a randomised cohort. PARTICIPANTS 135 people with sciatica in primary care. OUTCOME MEASURES Kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK), disability with the Roland Morris Disability Questionnaire (RDQ), and health-related quality of life with the EQ-5D and the 36-item Short Form (SF-36) Physical Component Summary. Participants also answered a newly devised substitute question for each questionnaire on an 11-point numerical rating scale. Global perceived effect and severity of leg pain were recorded at 1 year follow-up. RESULTS The correlation coefficient between the TSK and its substitute question was r=0.46 (p<0.001). The substitute question was better at predicting pain severity in the leg at 1 year follow-up than the TSK (addition of explained variation of 11% versus 4% in a logistic regression analysis). The TSK and its substitute question did not significantly differ in their prediction of global perceived effect at 1 year follow-up. The other substitute questions and both the RDQ and EQ-5D did not contribute significantly to one or both of their prediction models. CONCLUSION It may be feasible to replace the TSK by a single substitute question for predicting outcome in people with sciatica in primary care. The other substitute questions did not consistently predict outcome at 1 year follow-up.
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Kamper SJ, Stanton TR, Williams CM, Maher CG, Hush JM. How is recovery from low back pain measured? A systematic review of the literature. 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 2010; 20:9-18. [PMID: 20552378 DOI: 10.1007/s00586-010-1477-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 04/29/2010] [Accepted: 06/03/2010] [Indexed: 10/19/2022]
Abstract
Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of 'completely recovered'. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.
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Affiliation(s)
- Steven J Kamper
- The George Institute for International Health, University of Sydney, Missenden Road, Sydney, NSW 2050, Australia.
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Van Boxem K, Cheng J, Patijn J, van Kleef M, Lataster A, Mekhail N, Van Zundert J. 11. Lumbosacral radicular pain. Pain Pract 2010; 10:339-58. [PMID: 20492580 DOI: 10.1111/j.1533-2500.2010.00370.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms and/or symptoms of decreased function. The annual prevalence in the general population, described as low back pain with leg pain traveling below the knee, varied from 9.9% to 25%, which means that it is presumably the most commonly occurring form of neuropathic pain. The patient's history may give a suggestion of lumbosacral radicular pain. The best known clinical investigation is the straight-leg raising test. Final diagnosis is made based on a combination of clinical examination and potentially additional tests. Medical imaging studies are indicated to exclude possible serious pathologies and to confirm the affected level in patients suffering lumbosacral radicular pain for longer than 3 months. Magnetic resonance imaging is preferred. Selective diagnostic blocks help confirming the affected level. There is controversy concerning the effectiveness of conservative management (physical therapy, exercise) and pharmacological treatment. When conservative treatment fails, in subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation, transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can be considered (2 B+/-), preferentially study-related. In patients with a therapy-resistant radicular pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended (2 A+). This treatment should be performed in specialized centers.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Fritz JM, Thackeray A, Childs JD, Brennan GP. A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale. BMC Musculoskelet Disord 2010; 11:81. [PMID: 20433733 PMCID: PMC2874768 DOI: 10.1186/1471-2474-11-81] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 04/30/2010] [Indexed: 11/16/2022] Open
Abstract
Background Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery. A period of non-surgical management is recommended for most patients, but there is little evidence to guide non-surgical decision-making. We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The results suggested this approach may be effective, particularly in a more specific sub-group of patients. The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation, and within the pre-defined sub-group. Methods/Design The study will recruit 120 patients with low back pain and signs of nerve root irritation. Patients will be randomized to receive an extension-oriented treatment approach, with or without the addition of mechanical traction. Randomization will be stratified based on the presence of the pre-defined sub-grouping criteria. All patients will receive 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments will occur after 6 weeks, 6 months, and 1 year. The primary outcome will be disability measured with a modified Oswestry questionnaire. Secondary outcomes will include self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups, and examine the interaction between treatment and sub-grouping status. Discussion This trial will provide a methodologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation, and will examine the validity of a pre-defined sub-grouping hypothesis. The results will provide evidence to inform non-surgical decision-making for these patients. Trial Registration This trial has been registered with http://ClinicalTrials.gov: NCT00942227
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Affiliation(s)
- Julie M Fritz
- Rehabilitation Agency, Intermountain Healthcare, Salt Lake City, Utah, USA.
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Abstract
BACKGROUND Policy makers, payers, and other stakeholders increasingly call for greater evidence of the cost-effectiveness of health care interventions. OBJECTIVE The purposes of this study were to identify and rate the quality of cost analysis literature in physical therapy and to report summary information on the findings from the reviewed studies. DESIGN This study was a targeted literature review and rating of relevant studies published in the last decade using a quality evaluation tool for economic studies. MEASUREMENTS The Quality of Health Economic Studies (QHES) instrument was used to obtain quality scores. RESULTS Ninety-five in-scope studies were identified and rated using the QHES instrument. The average quality score was 82.2 (SD=15.8), and 81 of the studies received a score of 70 or higher, placing them in the "good" to "excellent" quality range. Investigators in nearly two thirds of the studies found the physical therapy intervention under investigation to be cost-effective. LIMITATIONS The small number of studies meeting the inclusion criteria was a limitation of the study. CONCLUSIONS The quality of the literature regarding the cost-effectiveness of physical therapy is very good, although the magnitude of this body of literature is small. Greater awareness of the strengths and limitations of cost analyses in physical therapy should provide guidance for conducting high-quality cost-effectiveness studies as demand increases for demonstrations of the value of physical therapy.
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Effizienz einer minimalen psychosozialen Intervention bei Patienten mit subakuten Kreuzschmerzen. MANUELLE MEDIZIN 2008. [DOI: 10.1007/s00337-007-0570-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Luijsterburg PAJ, Verhagen AP, Ostelo RWJG, van den Hoogen HJMM, Peul WC, Avezaat CJJ, Koes BW. Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up. 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 2008; 17:509-17. [PMID: 18172697 PMCID: PMC2295266 DOI: 10.1007/s00586-007-0569-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 09/25/2007] [Accepted: 12/02/2007] [Indexed: 11/28/2022]
Abstract
A randomised clinical trial in primary care with a 12-months follow-up period. About 135 patients with acute sciatica (recruited from May 2003 to November 2004) were randomised in two groups: (1) the intervention group received physical therapy (PT) added to the general practitioners’ care, and (2) the control group with general practitioners’ care only. To assess the effectiveness of PT additional to general practitioners’ care compared to general practitioners’ care alone, in patients with acute sciatica. There is a lack of knowledge concerning the effectiveness of PT in patients with sciatica. The primary outcome was patients’ global perceived effect (GPE). Secondary outcomes were severity of leg and back pain, severity of disability, general health and absence from work. The outcomes were measured at 3, 6, 12 and 52 weeks after randomisation. At 3 months follow-up, 70% of the intervention group and 62% of the control group reported improvement (RR 1.1; 95% CI 0.9–1.5). At 12 months follow-up, 79% of the intervention group and 56% of the control group reported improvement (RR 1.4; 95% CI 1.1; 1.8). No significant differences regarding leg pain, functional status, fear of movement and health status were found at short-term or long-term follow-up. At 12 months follow-up, evidence was found that PT added to general practitioners’ care is only more effective regarding GPE, and not more cost-effective in the treatment of patients with acute sciatica than general practitioners’ care alone. There are indications that PT is especially effective regarding GPE in patients reporting severe disability at presentation.
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Affiliation(s)
- Pim A J Luijsterburg
- Department of General Practice, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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