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

2. 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:

3. 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

4. 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

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

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

7. 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

8. 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

9. 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

10. 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

11. 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?

12. 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)

13. 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?)

14. 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

15. 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

16. 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

17. 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)

18. 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.

19. 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, doi: /s [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), doi: /BRS [doi]

20. Questions?