Does motor control training improve pain and function in adults with symptomatic lumbar disc herniation? A systematic review and meta-analysis of 861 subjects in 16 trials

[Conservative therapy for lumbar disc herniation]

BACKGROUND

Herniated discs are a common cause of neurological symptoms that often lead to reduced quality of life. They affect around 20% of 45-56-year olds and, therefore, represent a correspondingly major challenge for healthcare. Conservative therapy methods are usually used as the first treatment option; surgical interventions should only be considered in special symptom constellations.

AIM

This study aims to evaluate the effectiveness of conservative therapy methods in the treatment of lumbar disc herniation and to demonstrate their influence on pain reduction and functional improvement.

MATERIAL AND METHODS

The current valid AWMF guideline was analyzed, and a systematic literature search was conducted to identify relevant information on the conservative treatment of herniated discs. The therapeutic approaches analyzed included physiotherapy, drug treatment, manual therapy and injection therapies. Inclusion criteria covered reviews and meta-analyses from 2019 to 2024.

RESULTS

The analysis showed that conservative treatment methods led to a significant reduction in pain and improvement in functional abilities in the majority of patients. Not all frequently clinical used forms of therapy have been well proven.

DISCUSSION

The results of this study underline the importance of conservative treatment methods as an effective treatment option for herniated discs. In particular, the combination of different treatment approaches can improve treatment outcomes. However, further long-term studies are needed to determine the long-term effects and optimal treatment protocols.

Efficacy of percutaneous endoscopic lumbar discectomy (PELD) combined with sinuvertebral nerve ablation versus PELD for low back pain in lumbar disc herniation

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has demonstrated variable efficacy in alleviating low back pain (LBP) associated with lumbar disc herniation (LDH). Sinuvertebral nerve ablation (SNA), which targets the nociceptive pathway implicated in discogenic LBP pathogenesis, has emerged as a potential adjunctive therapy. The efficacy of endoscopic radiofrequency ablation in enhancing PELD for the treatment of LBP in patients with LDH remains unclear.

METHODS

A retrospective cohort study was conducted on LDH patients with concomitant LBP treated at the Spinal Surgery Department, China-Japan Friendship Hospital, from June 2020 to June 2023. Participants were categorized into two groups: PELD combined with SNA (n = 51) and PELD alone (n = 46). Primary outcome measures included the Visual Analog Scale (VAS) for pain, the Japanese Orthopaedic Association (JOA) score, and the Oswestry Disability Index (ODI) at baseline and 1-, 3-, and 6-month follow-ups.

RESULTS

Both groups exhibited significant improvements in VAS, JOA, and ODI scores for LBP and leg pain postoperatively compared to preoperative assessments. Notably, the PELD combined with SNA group demonstrated statistically significant superior outcomes in VAS, JOA, and ODI scores specifically for LBP compared to the PELD group.

CONCLUSION

The combination of PELD with SNA significantly improves LBP outcomes compared to PELD alone in LDH patients. While the observed improvements did not reach the minimal clinically important differences (MICD), these findings suggest that SNA may enhance the efficacy of PELD in LBP management.

The effect of lumbar multifidus muscle degeneration on upper lumbar disc herniation

Purpose

This study aimed to investigate the effect of lumbar multifidus muscle (MF) degeneration on upper lumbar disc herniation (ULDH).

Methods

This study used 3.0T magnetic resonance imaging (MRI) T2 axial weighted images to retrospectively analyze 93 ULDH patients and 111 healthy participants. Sixty-five pairs of participants were included in this study using propensity score matching (PSM). Cross-sectional area, fat infiltration area, anteroposterior diameter (APD), lateral diameter (LD), cross-sectional area of the bilateral multifidus muscles at the corresponding level, intervertebral disc area at the corresponding section, and visual analog scale (VAS) score for low back pain (LBP). For inter-group comparisons, we used the t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, chi-square test, or Fisher's exact test, according to the type of data. We used Pearson correlation analysis to study the correlation between the VAS score and related indicators, and established a predictive model for upper lumbar disc herniation using the receive operative characteristic (ROC) curve analysis method. Finally, univariate and multivariate logistic regression analyses were performed to establish a predictive model for the risk of high lumbar disc herniation.

Results

We compared the fat areas at the lumbar vertebral levels L1/2, L2/3, and L3/4, as well as the left lateral diameter (LD) (MF), L1/2 left lumbar multifidus muscle index (LMFI), and L1/2 total fat infiltration cross-section area (TFCSA), and found significant differences between the case and control groups (P < 0.001). Furthermore, we observed a significant positive correlation (P < 0.05) between the VAS scores and multiple muscle indicators. Additionally, we developed ROC prediction models to assess the risk of lumbar intervertebral disc protrusion at the L1/2, L2/3, and L3/4 levels, with the results identifying L1/2 TFCSA, L2/3 TFCSA, and L3/4 relative psoas major muscle cross-section area (rPMCSA) as the most predictive indicators. Finally, univariate and multivariate logistic regression analyses showed that the L1/2 rPMCSA, L2/3 TFCSA were significantly associated with the risk of lumbar intervertebral disc protrusion in both models.

Conclusion

Degeneration of the MF is significantly correlated with the occurrence of ULDH, and the larger the area of fat infiltration in the MF, the more obvious the lower back pain in ULDH patients. In addition, TFCSA can serve as an indicator of the occurrence of ULDH.

J. P. Rikers R, Pourahmadi M, Soltani Arabshahi SK, Keshtkar A, Dargahi H, Yaghmaei M, Monajemi A. Teaching and learning clinical reasoning skill in undergraduate medical students: A scoping review

BACKGROUND

Clinical reasoning involves the application of knowledge and skills to collect and integrate information, typically to arrive at a diagnosis, implement appropriate interventions, solve clinical problems, and improve the quality of health care and patient outcomes. It is a vital competency that medical students must acquire, as it is considered the heart of medicine.

PURPOSE

This scoping review aimed to identify and summarize the existing literature on learning and teaching strategies for improving clinical reasoning skill in undergraduate medical education.

METHODS

We conducted electronic searches in Scopus, PubMed/Medline (NLM), Web of Science (WOS), and ERIC to retrieve articles published between January 1, 2010, and March 23, 2024. We also performed hand searches by scanning the reference lists of included studies and similar reviews and searching three key journals. After removing duplicates, two reviewers independently extracted data from primary articles using a standard data extraction form. The authors used Arksey and O'Malley's framework.

RESULTS

Among the 46581 retrieved records, 54 full-text articles were included in the present review. We categorized the educational strategies based on their aspects, focus, and purpose. Included studies used various educational strategies for improving clinical reasoning skill in undergraduate medical education by serial cue or whole clinical cases that presented as process-oriented or knowledge-oriented.

CONCLUSION

This scoping review investigated various dimensions of educational intervention for improving clinical reasoning skill in undergraduate medical education. There is a need for more precision studies with larger sample sizes, designing studies according to randomized controlled trials standards, determining MCID, or performing meta-analyses to acquire robust and conclusive results.

A new technique for low back pain in lumbar disc herniation: percutaneous endoscopic lumbar discectomy combined with sinuvertebral nerve ablation

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has demonstrated efficacy in alleviating leg pain among patients with lumbar disc herniation. Nonetheless, residual back pain persists as a troubling issue for surgeons following the procedure. In the treatment of discogenic back pain, sinuvertebral nerve radiofrequency ablation has shown promising results. Nevertheless, the potential benefit of simultaneously implementing sinuvertebral nerve radiofrequency ablation during PELD surgery to address residual back pain has not been thoroughly investigated in current literature.

METHODS

This retrospective study reviewed Lumbar disc herniation (LDH) patients with low back pain who underwent combined PELD and sinuvertebral nerve ablation in our department between January 2021 and September 2023. Residual low back pain post-surgery was assessed and compared with existing literature.

RESULTS

A total of 80 patients, including 53 males and 27 females, were included in the study. Following surgical intervention, patients demonstrated remarkable improvements in pain and functional parameters. One month post-operatively, the VAS score for low back pain exhibited a 75% reduction (6.45 ± 1.3 to 1.61 ± 1.67), while the VAS score for leg pain decreased by 85% (7.89 ± 1.15 to 1.18 ± 1.26). Notably, the JOA score increased from 12.89 ± 5.48 to 25.35 ± 4.96, and the ODI score decreased form 59.48 ± 9.58 to 20.3 ± 5.37. These improvements were sustained at three months post-operatively. According to the modified Mac Nab criteria, the excellent and good rate was 88.75%. Residual low back pain is observed to be comparatively reduced compared to the findings documented in earlier literature.

CONCLUSION

The combination of percutaneous endoscopic lumbar discectomy and sinuvertebral nerve ablation demonstrates effective improvement in low back pain for LDH patients.

Effects of Multimodal Physical Therapy on Pain, Disability, H-reflex, and Diffusion Tensor Imaging Parameters in Patients With Lumbosacral Radiculopathy Due to Lumbar Disc Herniation: A Preliminary Trial

Background Lumbosacral radiculopathy (LSR) due to lumbar disc herniation (LDH) is a condition caused by mechanical compression of nerve roots. Various physical therapy interventions have been proposed for the conservative management of LSR due to LDH. However, the study of physical therapy interventions in a multimodal form is lacking. Additionally, the effect of physical therapy on diffusion tensor imaging (DTI) parameters of the compressed nerve root has not been studied. This study aimed to investigate the effects of multimodal physical therapy (MPT) on pain, disability, soleus H-reflex, and DTI parameters of the compressed nerve root in patients with chronic unilateral LSR due to LDH. Methods A prospective preliminary pre-post clinical trial with a convenience sample was conducted. A total of 14 patients with chronic unilateral LSR due to paracentral L4-L5 or L5-S1 LDH were recruited for the study. Participants received a total of 18 sessions of a six-week MPT program that consisted of electrophysical agents, manual therapy interventions, and core stability exercises. Electrophysical agents involved interferential current and hot pack. Manual therapy interventions included myofascial release, side posture positional distraction, passive spinal rotation mobilization, and high-velocity low-amplitude manipulation. Visual analog scale (VAS), Roland-Morris Disability Questionnaire (RMDQ), soleus H-reflex amplitude, side-to-side amplitude (H/H) ratio, fractional anisotropy (FA), and apparent diffusion coefficient (ADC) of the compressed nerve root were measured at baseline and post-intervention. Results There were significant improvements in VAS, RMDQ, H/H ratio, FA, and ADC of the compressed nerve root. Furthermore, significant improvement was found in the affected side compared with the contralateral side in H-reflex amplitude. Conclusions The observations of this preliminary trial suggest that MPT is a successful intervention in patients with chronic unilateral LSR due to LDH. Regarding DTI parameters of the compressed nerve root, FA increased and ADC decreased. Future studies with a control group, large sample sizes, and longer follow-up periods are needed.

Regression of a large prolapsed lumbar disc herniation achieved by conservative treatment: A case report and literature review

A common spinal condition known as lumbar disc herniation (LDH) can result in radicular and low back discomfort. A 27-year-old man was admitted to our hospital with a 6-year history of persistent low back pain, and his low back pain had recurred with radiation to his lower extremities over the last two months. An extensive right-sided paracentral disc herniation in the L5/S1 intervertebral region, which compressed the nerve root, was discovered by magnetic resonance imaging (MRI) of his lumbar spine. After receiving conservative treatment, the patient reported that his lower back discomfort and neurogenic claudication had gradually subsided after 4 months. After one year, a follow-up MRI showed that the massive, prolapsed disc herniation at the L5/S1 level had totally disappeared. The sagittal protrusion length of the L5/S1 intervertebral disc shrank from 12.35 mm to 3.49 mm. However, there remained a chance of vertebral height loss. During the course of treatment, the height of the L5/S1 intervertebral space was still slightly reduced. The intervertebral space height declined from 7.705 mm to 7.201 mm after one year of treatment. The current case and a review of the literature demonstrate that LDH can decrease with conservative therapy over a short period of time. We stress the effectiveness of conservative treatment in very select LDH cases that lack a clear surgical justification.

The effect of dual-task conditions on postural control in adults with low back pain: a systematic review and meta-analysis

BACKGROUND

Dual-task conditions, which involve performing two tasks simultaneously, may exacerbate pain and further impair daily functioning in individuals with low back pain (LBP). Understanding the effects of dual-task conditions on postural control in patients with LBP is crucial for the development of effective rehabilitation programs. Our objective was to investigate the impact of dual-task conditions on postural control in individuals with LBP compared to those without LBP.

METHODS

We conducted a comprehensive search of Medline via PubMed, Scopus, the Cochrane Central Register of Controlled Trials, Web of Science, and EMBASE databases, with no language restrictions, from inception to January 1, 2023. The primary outcome measures of the study were velocity, area, amplitude, phase plane portrait, and path/sway length of the center of pressure (CoP). Standardized mean difference (SMD) effect sizes were calculated, and the quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

From 196 studies, five involving 242 adults (≥ 18 years) met the inclusion criteria. Three studies were rated as high quality, while two were deemed moderate. In the included studies, 140 participants had non-specific LBP, while 102 participants did not report any symptoms, with mean ages of 36.68 (± 14.21) and 36.35 (± 15.39) years, respectively. Three studies had both genders, one exclusively included females, and one did not specify gender. Meta-analyses of primary outcomes revealed no significant differences in postural control between patients with LBP and pain-free controls during both easy and difficult postural tasks and cognitive load for velocity (easy: SMD - 0.09, 95% CI - 0.91 to 0.74; difficult: SMD 0.12, 95% CI - 0.67 to 0.91), area (easy: SMD 0.82, 95% CI - 2.99 to 4.62; difficult: SMD 0.14, 95% CI - 2.62 to 2.89), phase plane (easy: SMD - 0.59, 95% CI - 1.19 to 0.02; difficult: SMD - 0.18, 95% CI - 0.77 to 0.42), path/sway length (easy: SMD - 0.18, 95% CI - 0.77 to 0.42; difficult: SMD - 0.14, 95% CI - 0.84 to 0.55), and amplitude (easy: SMD 0.89, 95% CI - 1.62 to 3.39; difficult: SMD 1.31, 95% CI - 1.48 to 4.10).

CONCLUSIONS

The current evidence suggests that there are no significant differences in postural control parameters during dual-task conditions between individuals with non-specific LBP and pain-free subjects. However, due to the limited number of available studies, significant publication bias, and considerable statistical heterogeneity, definitive conclusions cannot be drawn. Therefore, further research comprising high-quality studies with larger sample sizes is necessary to obtain conclusive results. Trial registration PROSPERO CRD42022359263.