Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial

PurposeAlthough there is growing evidence in favour of the bio-psychosocial approach to the treatment of persistent neck pain, it is questioned whether treating psychological factors can improve patient perceptions of disability, pain and quality of life. This randomised, controlled study with 12 months’ follow-up was conducted to evaluate the efficacy of adding cognitive-behavioural principles to exercises for chronic neck pain.MethodsEighty patients were randomly assigned to the usual neck exercises plus cognitive-behavioural treatment (PTcb group, 40 subjects) or to treatment based on neck exercises alone (PT group, 40 subjects). Before treatment (T1), at the end of treatment (T2) and 12 months later (T3), all of the patients completed a booklet including the Neck Pain and Disability Scale, a numerical rating scale, and the Short-Form Health Survey Questionnaire (SF-36).ResultsThe present trial failed to demonstrate its primary end point: the pre- and post-treatment difference in total NPDS scores was not statistically different between groups. Disability improved similarly in both groups over time, remaining stable until T3 in the PTcb group and slightly increasing at the same time in the PT group. Pain trends were comparable, with both groups showing an improvement between T1 and T2, and a slight worsening between T2 and T3. There were significant increases in all of the SF-36 domains except for health in general, and vitality in both groups by the end of treatment. SF-36 showed a between-group difference only for the physical activity domain (10.4; 95 % CI 2.4–18.5).ConclusionDisability, pain and quality of life improved at the end of treatment in both groups, without differences between them.     

Therapeutic and stabilization exercises after manual therapy in patients with non-specific chronic neck pain: A randomised clinical trial

ObjectiveThis study aimed to determine and compare the effects of therapeutic and stabilization exercises prescribed to patients after manual therapy sessions on pain, neck range of motion and disability.MethodsThirty patients with non-specific chronic neck pain were recruited. After the initial examination, one session of manual therapy was conducted. The examinations were repeated to assess the effect of manual therapy on pain intensity and neck range of motion. After manual therapy, patients were randomly allocated into two groups: stabilization exercise group (SEG) and therapeutic exercise group (2 days/week/6 week). Pain intensity was assessed using the visual analog scale. Joint movements assessed using goniometer and the lateral scapular shift test for scapular dyskinesia. In addition, disability status was assessed using a neck disability index.ResultsIn all patients, manual therapy decreased pain intensity and increased joint movements (p < 0.05). After 6 weeks of exercise therapy, pain intensity, neck flexion, extension, lateral flexion movement and disability improved in SEG (p < 0.05).ConclusionThis study demonstrated that stabilization exercises combined with manual therapy had more positive effects among patients with non-specific chronic neck pain.Implications for practice

• •The treatment for non-specific chronic neck pain should be supported with exercises after manual therapy sessions for reducing neck pain.
• •Instead of therapeutic isometric exercises, which are often clinically prescribed as home exercises, stabilization exercises may be preferred as they are performed by maintaining the neutral position of the neck and include stretching.

     

Active treatment of chronic neck pain: a prospective randomized intervention

STUDY DESIGN: A randomized comparative study with single-blind outcome assessments. OBJECTIVES: To compare the efficacy of a multimodal treatment emphasizing proprioceptive training (ACTIVE) with activated home exercises (HOME) and recommendation of exercise (CONTROL) in patients with nonspecific chronic neck pain. SUMMARY OF BACKGROUND DATA: The efficacy of active exercises and passive physiotherapy for neck trouble has been somewhat disappointing in the previous few studies. METHODS: Seventy-six patients (22 men, 54 women) with chronic, nonspecific neck pain participated. Sixty-two participated the 1-year follow-up. Subjective pain and disability, cervical ranges of motion, and pressure pain threshold in the shoulder region were measured at baseline, at 3 months, and at 12 months. The ACTIVE treatment consisted of 24 sessions of proprioceptive exercises, relaxation, and behavioral support. The HOME regimen included a neck lecture and two sessions of practical training for home exercises and instructions for maintaining a diary of progress. The CONTROL treatment included a lecture regarding care of the neck with a recommendation to exercise. RESULTS: The average self-experienced total benefit was highest in the ACTIVE group, and the HOME group rated over the CONTROL group (P < 0.001). Differences between the groups in favor of the ACTIVE treatment were recorded in reduction of neck symptoms and improvements in general health and self-experienced working ability (P < 0.01-0.03). Changes in measures of mobility and pressure pain threshold were minor. CONCLUSIONS: Regarding self-experienced benefit, the multimodal treatment was more efficacious than activated home exercises that were clearly more efficacious than just advising. No major differences were noted in objective measurements of cervical function between the groups, but the content validity of these assessments in chronic neck trouble can be questioned.     

Evaluation of short-term and residual effects of Kinesio taping in chronic lateral epicondylitis: A randomized,double-blinded,controlled trial

BackgroundLateral epicondylitis is degenerative tendinosis of the extensor carpi radialis brevis muscle and is the most common work/sports-related chronic musculoskeletal problem affecting the elbow.PurposeThis study aimed to evaluate the short term and residual effectiveness of the Kinesio taping method on pain, grip force, quality of life, and functionality.Study DesignRandomized, double-blinded, controlled study.MethodsSubjects were 50 patients diagnosed with chronic unilateral lateral epicondylitis with a symptom duration of at least 12 weeks. During the first four weeks, the study group received a true inhibitor Kinesio taping while the control group received sham taping. In both groups, progressive stretching and strengthening exercises were given as a home program for six weeks. The primary outcome measure was the Numerical Rating Scale (NRS) for self-report of pain intensity; secondary outcome measures were Cyriax resistive muscle test evaluation, maximal grip strength, Patient- Rated Tennis Elbow Evaluation (PRTEE), and Short Form-36 (SF-36). After the treatment, patients were evaluated by the first assessor who was blinded to taping types.ResultsThere was a significant decrease in NRS scores overtime during the first four weeks in both groups (P < .001,) and effect sizes were large. There was no significant difference in Cyriax muscle resistance test maximal grip strength between groups (P > .05). However, there was a significant improvement in muscle strength of elbow extension and pronation in the study group detected in the intragroup analysis. Intragroup comparisons also showed a significant improvement in all subunits of the PRTEE and SF-36 except energy/vitality, social functioning, and pain in both groups (P < .05) with moderate to high effect sizes. PRTEE pain scores were significantly decreased in the study group compared to the placebo group (P < .05, d = 0.48).ConclusionThe effects of Kinesio taping on muscle strength, quality of life, and function in chronic lateral epicondylitis are not superior to placebo. However, NRS scores showed that in the two weeks after Kinesio taping treatment, pain reduction persisted as a residual effect which may improve the exercise adherence and functionality.     

Systematic review of manual therapies for nonspecific neck pain

ObjectiveTo evaluate the effectiveness of manual therapies in the treatment of nonspecific neck pain.Materials and methodsMedline and the Cochrane Library were searched for randomized controlled trials of manual therapy or mobilization, used alone or with exercises to treat pain and functional impairment related to nonspecific neck pain. Cochrane Back Review Group criteria were used to assess the quality of the trials and the level of evidence (unclear, limited, moderate, or high) for short-, medium-, and long-term effects.ResultsOf 27 identified trials, 18 were of high quality. In acute neck pain, effective treatments were thoracic manipulation combined with electrothermal therapy in the short term and cervical manipulation in the long term. In chronic neck pain and neck pain of variable duration, both pain and function improved consistently at all follow-up time points. None of the manual therapies used alone or in combination was superior over the others. In the long term, exercises alone or combined with manual therapies were superior over manual therapies used alone.ConclusionManual therapies contribute usefully to the management of nonspecific neck pain. The level of evidence is moderate for short-term effects of upper thoracic manipulation in acute neck pain, limited for long-term effects of neck manipulation, and limited for all techniques and follow-up durations in chronic neck pain.     

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty

Background contextMultilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach.PurposeTo elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study.Study designA prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty.Patient sampleIn total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3–C6 and C3–C7).Outcome measuresSelf-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales.MethodsComparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables.ResultsPosterior surgery took an hour shorter (p<.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group.ConclusionsOur study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.     

Outcomes of cervical disc replacement in patients with neck pain greater than arm pain

BACKGROUND CONTEXTAlthough anterior cervical discectomy and fusion is believed to positively impact a patient's radicular symptoms as well as axial neck pain, the outcomes of cervical disc replacement (CDR) with regards to neck pain specifically have not been established.PURPOSEPrimary: to assess clinical improvement following CDR in patients with neck pain greater than arm pain. Secondary: to compare the clinical outcomes between patients undergoing CDR for predominant neck pain (pNP), predominant arm pain (pAP), and equal neck and arm pain (ENAP).STUDY DESIGNRetrospective review of prospectively collected data.PATIENT SAMPLEPatients who had undergone one- or two-level CDR for the treatment of degenerative cervical pathology and had a minimum of 6-month follow-up were included and stratified into three cohorts based on their predominant location of pain: pNP, pAP, and ENAP.OUTCOME MEASURESPatient-reported outcomes: Neck Disability Index (NDI), Visual Analog Scale (VAS) neck and arm, Short Form 12-Item Physical Health Score (SF12-PHS), Short Form 12-Item Mental Health Score (SF12-MHS), minimal clinically important difference (MCID).METHODSChanges in Patient-reported outcomes from preoperative values to early (<6 months) and late (≥6 months) postoperative timepoints were analyzed within each of the three groups. The percentage of patients achieving MCID was also evaluated.RESULTSOne hundred twenty-five patients (52 pNP, 30 pAP, 43 ENAP) were included. The pNP cohort demonstrated significant improvements in early and late NDI and VAS-Neck, early SF-12 MCS, and late SF-12 PCS. The pAP and ENAP cohorts demonstrated significant improvements in all PROMs, including NDI, VAS-Neck, VAS-Arm, SF-12 PCS, and SF-12 MCS, at both the early and late timepoints. No statistically significant differences were found in the MCID achievement rates for NDI, VAS-Neck, SF-12 PCS, and SF-12 MCS at the late timepoint amongst the three groups.CONCLUSIONSCDR leads to comparable improvement in neck pain and disability in patients presenting with neck pain greater than arm pain and meeting specific clinical and radiographic criteria.     

Neuromuscular exercises on pain intensity,functional disability,proprioception, and balance of military personnel with chronic low back pain

BackgroundDue to their occupational status, military personnel are a high-risk group for low back pain (LBP).PurposeThe aim of this study was to investigate the effect of neuromuscular exercises on the severity of pain, functional disability, proprioception, and balance in military personnel with LBP.MethodsMilitary personnel with LBP were randomly assigned into two groups: intervention (n=15) and control (n=15). The intervention group performed 60 minutes of neuromuscular exercises three times per week for eight weeks while the control group continued their routine physical activities.ResultsThe mean post-intervention pain intensity, disability, and proprioception error significantly decreased in the intervention group. Whereas their mean post-interventions static and dynamic balance scores significantly increased.ConclusionsThe results indicate eight weeks of neuromuscular exercise decreased pain intensity and improved functional ability, static and dynamic balance, and proprioception among military staff suffering chronic low back pain.     

Long-term quality of life outcome after spondylodiscitis treatment

BACKGROUND CONTEXTSpondylodiscitis is the most common spinal infection of which the incidence has increased and the peak prevalence is between 50 and 70 years of age. Spondylodiscitis is often a complication of a distant infection. Early diagnosis can be challenging, and although improvements in diagnostic techniques and modern therapy have diminished the mortality of the disease, current literature about the outcome of spondylodiscitis is scarce.PURPOSETo evaluate the long-term clinical outcome of patients who suffered from spondylodiscitis.STUDY DESIGNA two-center cross-sectional study.PATIENT SAMPLEPatients with spondylodiscitis in two large teaching hospitals in the Netherlands between 2003 and 2017.OUTCOME MEASURESVisual Analogue Scale (VAS) for back pain, Oswestry Disability Index (ODI) for function, and Short Form 36 (SF-36) for general quality of life of spondylodiscitis patients.METHODEligible patients were identified from electronic patient databases and completed multiple patient reported outcome measures after obtaining informed consent. General demographic and clinical information (age, sex, medical history) were extracted from the patient records. SF-36 domain scores of spondylodiscitis patients were compared with a nationwide population sample.RESULTS183 patients were treated for spondylodiscitis; additional questionnaires were received from 82 patients. After a median follow-up of 63 months, the overall mortality was 28%. The mean VAS for back pain was 3.5, and the mean ODI score was 22. In all SF-36 domains a significantly lower score was found in the spondylodiscitis group compared with a normative national Dutch cohort. There was a strong correlation between back pain and ODI scores (ρ=0.81, p<.05).CONCLUSIONSOur study confirms that spondylodiscitis is a disease causing a profound impact on back pain, function and quality of life. The results suggest that chronic back pain is a debilitating problem, as it has an extensive influence on daily activities and social and psychological well-being, causing significant disability.     

Outcomes are not different for patient-matched versus nonmatched treatment in subjects with chronic recurrent low back pain: a randomized clinical trial

Background contextClassification schemas for low back pain (LBP), such as the Treatment-Based Classification and the Movement System Impairment, use common clinical features to subgroup patients with LBP and are purported to improve treatment outcomes.PurposeTo assess if providing matched treatments based on patient-specific clinical features led to superior treatment outcomes compared with an unmatched treatment for subjects with chronic recurrent LBP.Study designThis study is a randomized controlled trial.Patient sampleSubjects (n=124) with LBP (≥12 months) with or without recurrences underwent a standardized clinical examination to group them into one of two strata: ineligible or eligible for stabilization exercises based on the Treatment-Based Classification schema. Subjects underwent additional clinical tests to assign them to one of the five possible Movement System Impairment categories.Outcome measuresQuestionnaires were collected electronically at Week 0 (before treatment), Week 7 (after the 6-week 1-hour treatment sessions), and 12 months. Using the Oswestry disability index (0–100) and the Numeric Pain Rating Scale (0–10), the primary analysis was performed using the intention-to-treat principle. Secondary outcomes included fear-avoidance beliefs and psychosocial work-related and general health status.MethodsAfter subjects were categorized based on their particular clinical features using both the Treatment-Based Classification and Movement System Impairment schemas, they were randomized into one of two treatments using a 3:1 ratio for matched or unmatched treatments. The treatments were trunk stabilization exercise or Movement System Impairment–directed exercises.ResultsOf the patients allocated to treatment for this study, 76 received a matched treatment and 25 received an unmatched treatment. After treatment, both groups showed a statistically significant improvement in the primary outcome measures and almost all the secondary measures; however, the matched treatment group did not demonstrate superior outcomes at Week 7 or 12 months, except on one of the secondary measures (Graded Chronic Pain Scale [Disability Scale]) (p=.01).ConclusionsProviding a matched treatment based on either the Treatment-Based Classification or the Movement System Impairment classification schema did not improve treatment outcomes compared with an unmatched treatment for patients with chronic LBP, except on one secondary disability measure.     

Neck Disability Index,short form-36 physical component summary,and pain scales for neck and arm pain: the minimum clinically important difference and substantial clinical benefit after cervical spine fusion

Background ContextThe Neck Disability Index (NDI), the short form-36 (SF-36) physical component summary (PCS), and pain scales for arm and neck pain are increasingly used to evaluate treatment effectiveness after cervical spine surgery. The minimum clinically important difference (MCID) is a threshold of improvement that is clinically relevant to the patient. However, the true goal is to provide the patient with a substantial clinical benefit (SCB).PurposeThis study determines the MCID and SCB using common anchor-based methods for NDI, PCS, and pain scales for arm and neck pain in patients undergoing cervical spine fusion for degenerative disorders.Study Design/SettingThe study setting is a longitudinal cohort in a multisurgeon spine specialty clinic.Patient sampleThe sample comprises 505 patients who underwent a cervical fusion for degenerative spine conditions and who have prospectively collected outcome scores with a minimum 1-year follow-up.Outcome MeasuresThe outcome measures of the study were NDI, SF-36, and numeric rating scales for arm and neck pain.MethodsThe MCID and SCB values for NDI, PCS, and pain scales for arm and neck pain were determined using receiver operating characteristic (ROC) curve analysis with the Health Transition Item of the SF-36 as an anchor. The Health Transition Item asks a patient “Compared to one year ago, how would you rate your health in general now?” with answers ranging from “Much Better,” “Somewhat Better,” “About the Same,” “Somewhat Worse,” to “Much Worse.” An ROC curve was constructed for each measure. The ROC curve–derived MCID was the change score with equal sensitivity and specificity to distinguish the “Somewhat Better” from the “About the Same” patients. The ROC curve–derived SCB was the change score with equal sensitivity and specificity to distinguish the “Much Better” from the “Somewhat Better” patients. Distribution-based methods including the standard error of the mean and the minimum detectable change were also used to calculate MCID.ResultsThe calculated MCID is 7.5 for the NDI, 4.1 for SF-36 PCS, and 2.5 for arm and neck pain. The calculated SCB is 9.5 for the NDI, 6.5 for SF-36 PCS, and 3.5 for arm and neck pain.ConclusionsPatients with an eight-point decrease in NDI, a 4.1-point increase in PCS, and a three-point decrease in arm or neck pain can detect a minimally clinically important change. Patients with a 10-point decrease in NDI, a 6.5-point increase in PCS, and a four-point decrease in arm or neck pain can detect an SCB after cervical spine fusion.     

One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study

Background contextThe clinical entity “discogenic back pain” remains controversial at fundamental levels, including its pathophysiology, diagnostic criteria, and optimal treatment. This is true despite availability of four randomized trials comparing the efficacy of surgical and nonsurgical treatments. One trial showed benefit for lumbar fusion compared with unstructured nonoperative care, and three others showed roughly similar results for lumbar surgery and structured rehabilitation.PurposeTo compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels.DesignProspective observational cohort study.Patient samplePatients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area.Outcome measuresRoland-Morris back disability score (primary outcome), current rating of overall pain severity on a numerical scale, back and leg pain bothersomeness measures, the physical function scale of the short-form 36 version 2 questionnaire, use of medications for pain, work status, emergency department visits, hospitalizations, and further surgery.MethodsPatients receiving spine surgery within 6 months of enrollment were designated as the “surgical treatment” group and the remainder as “nonsurgical treatment.” Outcomes were assessed at 3, 6, 9, and 12 months after enrollment.ResultsWe enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons. Eighty-six patients (17%) had surgery within 6 months of enrollment. Surgery consisted of instrumented fusion (79%), disc replacement (12%), laminectomy, or discectomy (9%). Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery. Adjusting for baseline differences among groups, surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified (23-point) Roland disability questionnaire (primary outcome) 1 year after enrollment. Using a composite definition of success incorporating 30% improvement in the Roland score, 30% improvement in pain, no opioid pain medication use, and working (if relevant), the 1-year success rate was 33% for surgery and 15% for nonsurgical treatment. The rate of reoperation was 11% in the surgical group; the rate of surgery after treatment designation in the nonsurgical group was 6% at 12 months after enrollment.ConclusionsThe surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines.     

腰椎椎管狭窄症融合方式的选择

目的探讨不同融合方式治疗退行性腰椎椎管狭窄症(degenerative lumbar spinal stenosis,DLSS)的疗效差异。方法回顾分析38例DLSS患者资料,所有患者均行腰后路蝶形减压,椎弓根钉内固定。依据有无椎间融合分为A、B组。A组21例行椎间融合及后外侧融合;B组17例未行椎间融合仅行后外侧融合。术后平均随访2年,应用健康状况调查简表(MOS item short form health survey,SF-36),Oswestry功能障碍指数(Oswestry disability index,ODI),疼痛视觉模拟量表(visual analogue scale,VAS)量表评估2种不同融合方式的疗效差异。结果 SF-36评分显示38例腰椎手术疗效显著(P0.01),且2种融合方式疗效差异无统计学意义(P0.05)。结论 2种融合方式治疗腰椎椎管狭窄症疗效无明显差异。     

经皮椎体成形术治疗以脊柱源性腹痛为主要症状的骨质疏松性椎体压缩性骨折

目的:分析经皮椎体成形术对以脊柱源性腹痛为主要症状的骨质疏松性椎体压缩性骨折的疗效。方法:回顾性分析2015年1月至2021年1月就诊的37例骨质疏松性椎体压缩性骨折患者,患者均以脊柱源性腹痛为主要症状,根据治疗方法不同分为手术组(21例)和保守组(16例)。手术组患者采用经皮椎体成形术治疗,男7例,女14例,年龄(75.95±6.84)岁,病程(5.26±3.79) d。保守组患者采用非手术治疗,男5例,女11例,年龄(75.50±8.07)岁,病程(4.28±3.42) d。两组患者术前主要表现为腹痛、腹胀或便秘,均无明显胸腰背部疼痛症状,经胸腰椎MRI确诊为新鲜的骨质疏松性椎体压缩性骨折,术后记录其腹痛视觉模拟评分(visual analogue scale,VAS),简明健康状况调查表(medical outcomes study short form-36,SF-36)评分,治疗后排便时间等。结果:37例患者均获得随访,随访时间手术组(14.90±14.11)个月,保守组(21.42±17.53)个月。两组患者治疗前基线资料比较差异无统计学意义(P>0.05)。相较于治疗前,手术组治疗后各时段VAS、保守组治疗后1个月VAS、两组治疗后3个月SF-36中8个维度评分均较术前明显改善(P<0.05);保守组治疗后3 d VAS与术前比较差异无统计学意义(P>0.05)。治疗前1 d 的VAS、SF-36中8个维度评分组间比较差异无统计学意义(P>0.05),治疗后3 d 的VAS、治疗后3个月生活活力及社会功能维度评分、治疗后排便时间手术组均优于保守组(P<0.05),其余指标差异无统计学意义(P>0.05)。手术组患者切口愈合良好,两组患者均无严重并发症发生。结论:经皮椎体成形术是治疗以脊柱源性腹痛为主要症状的骨质疏松性椎体压缩性骨折有效的方法,与保守治疗相比,在早期缓解腹痛及便秘症状、恢复生活活力及社会功能方面更有优势。     

牵伸训练治疗跖筋膜炎的病例对照研究

目的:评价牵伸训练联合双氯芬酸二乙胺超声透入以及牵伸训练联合脉冲超声波对跖筋膜炎的治疗效果,并比较其疗效。方法:自2009年6月至2012年3月治疗跖筋膜炎30例,分为3组:超声透入加牵伸组,脉冲超声波加牵伸组,单纯牵伸组,各10例。牵伸组男2例,女8例,平均年龄(46.7±6.5)岁,体质指数(26.7±2.8)kg/m2;脉冲超声波加牵伸组男4例,女6例,平均年龄(45.8±6.1)岁,体质指数(26.4±3.4)kg/m2;超声透入加牵伸组男3例,女7例,平均年龄(48.4±8.0)岁,体质指数(25.4±3.0)kg/m2。超声透入加牵伸和脉冲超声波加牵伸组的超声治疗每日10min,每周治疗5次,共4周,其中超声透入加牵伸组耦合剂使用双氯芬酸二乙胺(扶他林)。另外,所有患者进行小腿后群肌、跟腱及跖筋膜的牵伸训练。在治疗前、治疗后即刻及治疗3个月后,以视觉类比标度(visual analog scale,VAS)评价晨起足跟痛,并抽取足部功能指数量表(foot function index,FFI)中的行动障碍子量表评价患足功能状态。结果:治疗前3组患者资料和足跟痛起始状态组间无明显差异。晨痛及行动障碍的改善:治疗1个月时超声透入加牵伸组改善较单纯牵伸组明显(P<0.05),3个月时3组差异无统计学意义(P>0.05)。而组内比较显示3组晨痛及行动障碍在治疗前后的3个时间点均得到有效改善(P<0.05)。结论:单纯牵伸训练以及联合超声透入或脉冲超声波对治疗跖筋膜炎的晨痛和功能障碍均有效,而联合超声透入治疗效果最佳。     

Establishing a relationship using CT between facet distraction and clinical outcomes after ACDF

BACKGROUND CONTEXTAnterior cervical discectomy and fusion (ACDF), the gold standard treatment for radiculopathy and myelopathy, has the potential risk of inducing facet-mediated pain through over-distraction. However, the relationship between the clinical outcomes and facet distraction after ACDF remains unclear.PURPOSETo measure facet distraction using computed tomography (CT) and compare the results with the clinical outcomes after ACDF.STUDY DESIGNRetrospective cohort study.PATIENT SAMPLEA consecutive series of patients (n = 144) who underwent a single-level ACDF were included.OUTCOME MEASURESInterfacet distance on preoperative and postoperative lateral cervical radiographs and CT. Visual analog scale for neck pain (VASn), and arm pain (VASa), neck disability index (NDI), the Short Form 36-item health survey (SF-36) were used for clinical outcomes.METHODSEach patient underwent plain radiography of the lateral cervical spine preoperatively, immediately and two years postsurgery. CT was performed preoperatively, and at 3 days and 1-year postsurgery. The inter-facet distance was measured at each time point, and changes in values from the preoperative distance were noted and used for study. Patient-reported outcome measures were obtained preoperatively and at 2-year follow-up. Receiver operating characteristic (ROC) curves were generated to derive the critical facet distraction point.RESULTSThe 3 weeks postoperative VASn score was the most severe and showed a tendency to decrease during the follow-up period. There was a significant positive correlation between the change value of facet distraction measured using CT and 3 weeks postoperative VASn score. ROC curve analysis showed that the cut-off value of Δ facet distraction was 1.8 mm. The over-distraction group (Δ facet distraction ≥1.8 mm, n = 75) showed significantly worse clinical outcomes than the control group (Δ facet distraction <1.8 mm, n = 69), including neck and arm pain VAS scores at all time points until the final 2-year follow-up.CONCLUSIONThe change value of facet distraction measured using CT rather than plain radiography correlated better with neck pain, and over-distraction contributed to adverse long-term outcomes, including neck and arm pain after ACDF. Additionally, an over-distraction of ≥1.8 mm may cause radiculopathy of adjacent segments along with facet-mediated axial pain; therefore, cage height should be carefully determined to avoid over-distraction during ACDF.     

The development of a model for translation of the Neck Disability Index to utility scores for cost-utility analysis in cervical disorders

Background contextThe Neck Disability Index (NDI) is a commonly used disease-specific instrument for cervical spine disorders with good responsiveness and psychometric properties compared with general health status measures. However, NDI scores are unitless and do not have an intrinsic value that is comparable to other health status measures, and these scores have limited value in cost-utility analysis. The translation of disease-specific measures to Short Form-6 Dimensions (SF-6D) utility scores may be useful in cost-utility analysis.PurposeThe purpose of this study is to present a model for translating the NDI to SF-6D utility scores, permitting the use of NDI scores in the cost-utility analysis of cervical disorders.Study design/settingA secondary analysis of a multicenter prospective clinical trial of the Synthes ProDisc-C (Synthes, West Chester, PA, USA) was performed.Patient samplePatients included were randomized to receive either a total disc arthroplasty or anterior cervical discectomy and fusion for treatment of symptomatic cervical disc disease involving one vertebral level between C3 and C7. All subjects completed NDI and 36-Item Short Form Health Survey (SF-36) self-assessments at preoperative and postoperative follow-ups of 6 weeks, 3, 6, 12, 18, and 24 months.Outcome measuresThe NDI is a validated and widely used self-reported questionnaire designed to assess patient-determined disability resulting from neck pain, including pain level and effects on activities of daily living. The SF-6D is a preference-based health state classification system derived from six health dimensions of the SF-36 self-reported questionnaire, including the domains of physical functioning, role limitation, social functioning, bodily pain, mental health, and vitality.MethodsThe collected data points were divided into two cohorts: one for model formation and one for the assessment of model validity. SF-36 scores were converted to SF-6D utilities via three previously published methods. Correlation analyses and linear regression modeling between SF-6D and NDI created the models for translating scores. For validation, Spearman and Pearson correlations were calculated between the observed and predicted SF-6D utilities, and prediction errors were calculated.ResultsFour hundred thirty patients with 2,137 time points were used for creation and validation of the model. Pearson and Spearman correlation coefficients between the NDI and the SF-6D derived from each conversion method were found to be between ?0.8255 and ?0.8504 (p<.01). R² values ranged from 0.68 to 0.71 and root mean squared error (RMSE) from 0.092 to 0.084. Correlations between estimated and observed SF-6D scores ranged from 0.8325 to 0.8372 (p<.01). The mean prediction error was less than 0.006, with standard deviation (SD) between 0.082 and 0.093.DiscussionCorrelations between NDI and SF-6D utility scores are strong and statistically significant. The model has a large R² and small RMSE. The prediction models produce a small mean prediction error, but the SD of the prediction errors is large. High correlations between NDI and SF-6D permit these models to be used to calculate overall utilities, changes in utilities, and quality-adjusted life-years for large data samples. However, the relatively large observed prediction error SDs may limit the accuracy of translation of individual data points or small sample sizes.     

SF-36 scores in degenerative lumbar spine disorders: Analysis of prospective data from 451 patients

Background?When using Health-Related Quality of Life (HRQoL) in assessing outcomes of treatment, normative data for different diagnoses are needed to allow cross-comparisons of existing and future studies. We determined the SF-36 scores in patients with surgical lumbar spine problems.

Methods?This is a prospective observational study of consecutive surgical patients in one institution. In addition to SF-36 questionnaire responses, local pain, radiating pain, analgesic intake and walking ability were recorded, together with several other demographic variables. 451 patients (50% women) with median age 52 (13–88) years, operated from 1998 through 2002, were included in the study.

Results?Preoperative SF-36 scores were significantly lower than those derived from previously published material (the general population, nonspecific low back pain (LBP) patients, other samples of non-LBP patients), also with the use of normbased scoring. Sick-leave and worker's compensation seemed to affect perceived Health-Related Quality of Life (HRQoL), but smoking habits did not. Some SF-36 domains showed a possible discriminating pattern between diagnoses.

Interpretation?HRQoL reported by patients scheduled for lumbar spine surgery was much worse than for the normal population and for LBP patients. The normative SF-36 values provided may be used as a benchmark in future studies.     

Testing minimal clinically important difference: consensus or conundrum?

Background ContextVarious methodologies have been used in attempting to elucidate a standard method for calculating minimal clinically important difference (MCID). A consensus-based decision (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials [IMMPACT] group) suggested a 30% reduction from baseline as a means to define the MCID of self-report back pain measures. Additionally, important psychometric issues need to be addressed regarding use of an independent measure of the same construct as an external criterion, instead of simply using another self-report measure, when using an anchor-based approach to MCID.PurposeThe purpose was to test the validity of recently published guidelines regarding MCID using self-report back pain measures and objective socioeconomic outcomes.Study Design/SettingThis is a prospective study assessing change scores on commonly used spinal pain assessment measures in patients with chronic disabling occupational spinal disorders (CDOSDs) treated in a regional referral rehabilitation center performing interdisciplinary functional restoration.Patient SampleThe study consisted of consecutive cohort of patients (N=1,180) with CDOSDs completing a functional restoration program.Outcomes MeasuresSelf-report measures including the Oswestry Disability Index (ODI) and the physical component summary (PCS) and mental component summary (MCS) of the Short Form-36 (SF-36) obtained before and after treatment, were compared with objective socioeconomically relevant outcomes obtained 1 year after treatment (ie, work status and additional health-care utilization), that were the external criteria for evaluating MCID.MethodsPre- to posttreatment improvement was calculated separately for each measure, and subjects were divided into two groups based on the change in scores relative to baseline: 30% or greater versus less than 30% improvement. One-year posttreatment objective socioeconomic outcomes were used as independent external criteria relevant to the CDOSD population. This population is often studied as the most costly and problematic cohort in spine care.ResultsThe ODI and SF-36 MCS were not associated with any of the objective 1-year outcomes used as external criteria. Reduced post-rehabilitation health-care utilization (based on the percentage of patients pursuing health care from a new provider) was weakly associated with 30% or greater improvement on the SF-36 PCS, relative to patients whose scores changed by less than 30% relative to baseline (17.0% vs. 21.1%). The same was true for the ODI and return-to-work.ConclusionsWhen objective and independent criteria are used (socioeconomic outcomes) in a CDOSD cohort, the 30% improvement in the ODI and SF-36 may not be a valid MCID index. This replicates similar conclusions made by an independent research group using a distribution-based approach to MCID. The validity of the MCID concept rests on future research using objective external criteria. Moreover, there remains a question whether the term “important” in MCID can be unequivocally and operationally defined as a reliable construct.     

The impact of physical and psychological pain management training on pain intensity,anxiety and disability in patients undergoing lumbar surgeries

BACKGROUND/CONTEXTLumbar surgery is one of the interventions performed for patients with degenerative conditions.PURPOSEThis study aimed to investigate the effect of pain management education on pain intensity, anxiety, and disability after the lumbar surgery.STUDY DESIGN/SETTINGThis randomized controlled trial was performed on 70 30-65-year-old patients with lumbar canal stenosis and lumbar disc herniation from 2018 to 2019.PATIENT SAMPLESeventy participants were randomly divided into a control and an intervention group by a randomized block design. Participants in the intervention group received in-person pain management training twice a week for seven 60-90-minute sessions.OUTCOME MEASURESAll participants in the two groups completed the study instruments (numeric rating scale [NRS], Oswestery disability index [ODI], and pain anxiety symptoms scale [PASS]) before, immediately after, and 3 months after the study.METHODSParticipants in the intervention group received in-person pain management training twice a week for seven 60-90-minute sessions. To analyze the treatment effects, repeated-measures multivariate analysis of variance (MANOVA) and effect sizes were used where appropriate and calculated by Partial ɳ². Clinical outcome (MDC) for pain intensity and PASS was also reported. For participants lost to follow-up, we also used an “intention-to-treat” (ITT) approach.RESULTSThe results of MANOVA indicated that there were significant differences between the two groups on ratings of pain intensity, anxiety, and disability. According to the MDC, the mean differences of pain intensity for the intervention group was also clinically improved. Meanwhile, the mean differences in pain anxiety between three different times in the two groups were not above the MDC (20.14), suggesting that the clinical improvements were not significant. The results were confirmed for all outcome measures; a statistically significant difference was found between the groups in ITT analyses (p<.001).CONCLUSIONSPhysical and psychological pain management education was shown to be effective in decreasing pain intensity, anxiety, and disability. This strategy may be beneficial for such patients. Variables such as smoking behavior, past history of psychological disorders, and previous surgeries should be considered in future studies.