Low Back Pain with Radiculopathy: Searching for the Magic Cure By Chris Millikan

Patient Profile 58 year-old African American female with L sided low back pain and radiculopathy Patient works 10 hour night shifts in a warehouse Takes care of two grandchildren after school PMH: diabetes History of neck pain Current meds: naproxen Never received PT before High fear avoidance beliefs Therapy Setting: outpatient clinic in a hospital Ex of fear avoidance:

Patient Impairments MMT: R hip flexion 4/5, L hip flexion 3+/5 ROM: Lumbar flexion 25% limited due to pain Lumbar extension 20% limited to pain. Asymmetrical: avoids extension to L Pain: 10/10 pain at work Neuro: Numbness/tingling in L LE Gait: Antalgic gait on L leg Decreased step length on R leg

ICF Model Health Conditions L-sided lumbago with radiculopathy Diabetes Impairments R hip flexion 4/5, L hip flexion 3+/5 Lumbar flexion 25% limited due to pain Lumbar extension 20% limited to pain. Extension is Asymmetrical: avoids extension to L 10/10 pain down L LE at work Numbness/tingling in L LE Antalgic gait on L leg Decreased step length on R leg Activity Limitations Difficulty walking or standing for long periods of time Difficulty bending and picking up objects Participation Restrictions Difficulty completely shifts at work Difficulty taking care of grandchildren Inability to sleep due to pain

My Question What factors are prognostic of whether a 58-year-old female’s symptoms of lumbar radiculopathy will improve in one year?

First Study Outcome prediction in chronic unilateral lumbar radiculopathy: prospective cohort study

Possible Prognostic Factors Sociodemographic variables Psychological variables Pain history Findings from clinical examination Imaging Part of bigger RCT on effect of caudal steroid epidural injections for chronic unilateral lumbar radiculopathy This treatment had no ST or LT effect, so the researchers figured they could use the data to investigate their question Inclusion criteria:chronic unilateral lumbar rad. Lasting more than 12 weeks. Leg pain comparable or worse than back pain. All pts verified condition with CTs or MRIs Exclusion criteria: unspecific LBP with referred leg pain Researchers analyzed these things as possible prognostic factors: sociodemographic variables, psychological variables, pain history, findings from clinical examination, and imaging

Findings Good prognosis with multidisciplinary approach Prediction of less pain: higher education and working full-time Factors that predicted decreased pain and increased function: Lower age and low fear avoidance beliefs ODI changed from 30 to 15.5 (14.4 pts) Leg pain from 50.6 to 23.0 (27.5 pts) LBP from 47.6 to 27.9 (17.9 pts) All had p values of .001 Defined high correlation between prognostic factors to be greater than .6 Duration of back pain not included in the analysis because duration of leg pain and back pain were highly correlated Used FABQ to determine work status (FABQ Work greater than or equal to 34) Lower age and and higher FABQ work were independent variables predicting a successful outcome on the ODI (in multivariable analysis) Predictors for the secondary outcome measures (leg and back pain): higher edu and working full time statistically significant predictors (P <.05) Muscle weakness also predicted decreased leg pain Reflex impairment predicted increased leg pain Lower age predicted decreaed back pain FABQ physical activity greater than 15 predicted increased back pain Discussion of surgical group: outcomes were the same as non surgical at 52 weeks follow up Had higher baseline scores for impairment and pain, improved significantly more but still didn’t achieve lower/higher scores than conservatie care group at year follow up

Prognostic Factors: What they Predict for my Patient Decreased pain Low age Higher FABQ work Working full time Muscle weakness Higher education level .94 .16 2.70 4.11 5.77 Increased function Increased pain Reflex impairment Higher FABQ physical activity .39 .31 ODI changed from 30 to 15.5 (14.4 pts) Leg pain from 50.6 to 23.0 (27.5 pts) LBP from 47.6 to 27.9 (17.9 pts) All had p values of .001 Least significant OR=low age Defined high correlation between prognostic factors to be greater than .6 Duration of back pain not included in the analysis because duration of leg pain and back pain were highly correlated Used FABQ to determine work status (FABQ Work greater than or equal to 34) Lower age and and higher FABQ work were independent variables predicting a successful outcome on the ODI (in multivariable analysis) Predictors for the secondary outcome measures (leg and back pain): higher edu and working full time statistically significant predictors (P <.05) Muscle weakness also predicted decreased leg pain Reflex impairment predicted increased leg pain Lower age predicted decreaed back pain FABQ physical activity greater than 15 predicted increased back pain Discussion of surgical group: outcomes were the same as non surgical at 52 weeks follow up Had higher baseline scores for impairment and pain, improved significantly more but still didn’t achieve lower/higher scores than conservatie care group at year follow up

Limitations of Study Surgical and non surgical patients included Go through study What they did What they found And here’s whiy its important to the patient A couple minutes of intro, 3-4 minutes per study, 3-4 minutes for wrap up 15-20 slides

Implications of Study My patient’s characteristics that offer good prognosis: Working full-time Patient characteristics that offer bad prognosis High fear avoidance beliefs Higher age Education level not investigated Change in treatment plan: focus on reducing fear avoidance behavior Who cares? Why do I care? What should I have done based on learning this? What did you do that is in line with this evidence?

Second Study Preoperative Pain Neuroscience Education for Lumbar Radiculopathy Does neuroscience education affect outcomes with regard to: pain function surgical experience health care utilization post surgery What is usual care? Usual preop education Surgeons had to complete spine surgery education questionaaire (SSEQ) to determine if their education followed the usual care established in SSEQ study So what is NE? Discuss centralization, peripheralization, Aps, neuroplasticity, the decision to have LS, calming the nervous system, recovery after LS, scientific evidence for NE content, and an opportunity to reflect and write questions to ask the surgeon prior to surgery Patients asked to read NE booklet once before and once after surgery radiographs and PT used significantly less by EG Primary outcome measures of interest: back pain and leg pain and function MDC for NPRS is 2.1 Perceived disability measured with Oswestry (valid and reliable)-MDC= 5 points (10%) Other outcome measures: Post-op thoughts/beliefs Health care utilization post LS 65 participants Control group: usual care Experimental group: usual care + NE 67 participants (one in each group did not undergo surgery, so 65 for follow-up post surgery) Of the 65, 4 patients were lost to follow-up (3 from ECG, 1 from UCG) 3 Inclusion criteria: Age 18-65, willing to comply with follow-ups, post-op questionnaires 7 Exclusion criteria: Outside of age range, not proficient in English language, scheduled for LS involving instrumentation (spinal fusion, arthroplasty), participation in formal back school or multidisciplinary pain management program, undergoing LS for a condition other than lumbar radiculopathy, presence of chronic pain-related conditions, symptoms of cord compression Control group:usual care Experimental group: usual care + NE (1 pre op educational session within a week of surgery Sample size based on an interaction effect for a 2 x 5 mixed factorial analysis of variance using 70% power and a df of 2 (they estimated effective sample size to be between 56 and 99)

Leg Pain Comparison To ascertain the differences between treatment and control, researchers conducted a 2 x 5 analysis of variances on 3 different outcome measures Accounted for drop outs by only using the data before they dropped out (probably should have just dropped them completely huh?)

LBP and ODI comparison No significant differences in leg pain, back pain, Oswestry, EG: more favorable postop opinion than the UCG Overall costs of medical treatment lower for EG than UCG

Post op thoughts about surgery No significant differences in leg pain, back pain, Oswestry, EG: more favorable postop opinion than the UCG Overall costs of medical treatment lower for EG than UCG

Healthcare Expense Findings Compared total medical costs between groups using t tests No significant differences in leg pain, back pain, Oswestry, EG: more favorable postop opinion than the UCG Overall costs of medical treatment lower for EG than UCG

Limitations of Study Limited application to my patient: my patient did not have surgery More pain science education sessions could have produced a greater effect Standard preop education could have been less comprehensive/reassuring Sample size could have been bigger (65 participants)

Implications of Study Pain science education can improve prognosis for patients suffering from LBP Postop protocol very similar to conservative treatment Will reduce patient anxiety about pain Will reduce visits to medical establishments Change in my patient’s treatment? Educate on pain science first visit Follow-up suggestion: same question for conservative therapy for LBP patients with radiculopathy Many studies investigating pain science edu on outcomes for chronic LBP with positive outcomes. No study to my knowledge investigates radiculopathy specifically.

References Iversen, T., Solberg, T. K., Wilsgaard, T., Waterloo, K., Brox, J. I., & Ingebrigtsen, T. (2015). Outcome prediction in chronic unilateral lumbar radiculopathy: Prospective cohort study. BMC Musculoskeletal Disorders, 16, 17-015-0474-9. doi:10.1186/s12891-015-0474-9 [doi] Louw, A., Diener, I., Landers, M. R., & Puentedura, E. J. (2014). Preoperative pain neuroscience education for lumbar radiculopathy: A multicenter randomized controlled trial with 1-year follow-up. Spine, 39(18), 1449-1457. doi:10.1097/BRS.0000000000000444 [doi]

Questions?