Immediate preoperative outcomes of pain neuroscience education for patients undergoing total knee arthroplasty: A case series

Background: Standard preoperative education for total knee arthroplasty (TKA) has been shown to have no effect on postoperative outcomes. This may be because such education programs fail to educate patients about pain. Pain neuroscience education (PNE) focuses on teaching people more about pain from a neurobiological and neurophysiological perspective. Design and setting: Case Series. Aim: To determine the immediate effects, if any, of providing PNE before TKA surgery on patient self-report measures. Participants: Twelve patients (female = 10) prior to TKA for knee osteoarthritis (OA). Intervention: Preoperative educational session by a physical therapist on the neuroscience of pain, accompanied by an evidence-based booklet. Main outcome measures: Comparison of pre- and post-PNE self-report measures on knee pain (NPRS), Pain Catastrophization Scale (PCS), fear of movement (TSK), and beliefs about TKA; as well as three physical performance measures – knee flexion active range of motion, 40 m self-paced walk, and pressure pain threshold (PPT). Results: Immediately following the PNE, patients had statistically significant lower TSK scores, increased PPT, and improved beliefs about their upcoming surgery. There were no significant changes in knee pain, function, or flexion active range of motion. Conclusions: Results appear to suggest that immediately after PNE, patients scheduled for TKA had statistically significant changes in fear of movement, decreased sensitivity to pain and positive shifts in their beliefs about their future knee surgery. Larger trials with control/comparison groups are warranted to determine the true effects of preoperative PNE for patients about to undergo TKA.     

Primary lumbar hernia: A rare case report and a review of the literature

Primary lumbar hernia is a rarely encountered hernia. Surgical correction is the standard treatment for lumbar hernia, and either an open or laparoscopic procedure can be performed with equivalent success. However, open repairs are most commonly performed. Here, we present a case of a primary lumbar hernia that was successfully treated laparoscopically and discuss surgical modalities of treatment reported in the literature. There are two laparoscopic approaches: transabdominal and extraperitoneal. The main advantage of the laparoscopic approach is that it helps the surgeon to precisely locate and evaluate the characteristics of the defect. It also has a lower morbidity rate, shorter length of hospital stay, less postoperative pain, and an earlier return to daily routine activities than the open approach. In the present study, a patient with a superior lumbar hernia was treated laparoscopically by the transabdominal approach. Laparoscopic repair in such cases is feasible and achieves a good result when done by an experienced laparoscopic hernia surgeon.     

Preoperative education for orthopaedic patients: systematic review

AIMS: This paper presents a systematic review whose aim was to describe the scope and methods of the current literature on preoperative patient education and to identify the effects of this education. BACKGROUND: Preoperative patient education is a common and important intervention in surgical nursing, yet there is very limited systematic evidence on its precise role. METHODS: The Medline, CINAHL, Eric, Psycinfo and Social Sciences Index databases and the Cochrane Library were searched, covering the period from the beginning of each database to April 2003. Studies were included if they concerned adult orthopaedic patients, preoperative nursing patient education and were based on randomized controlled or clinical trials. Meta-analysis was carried out where appropriate. RESULTS: We identified 11 articles involving 1044 participants. Most studies included one experimental and one control group; only two had more than one experimental and control group. The educational interventions varied widely, but the majority were based on written materials alone, or written materials in combination with other teaching methods. The most common outcome measures related to pain, knowledge, anxiety, exercises and length of stay, and the least common to self-efficacy and empowerment. The methodological quality of the studies varied. Almost all reported one or more statistically significant effects. Based on the findings of the meta-analysis, preoperative education appears to have some impacts on patients' anxiety and knowledge levels. CONCLUSIONS: The review clearly highlights the need for well-designed, methodologically sound research into the outcomes of patient education. It also points to the need to study patient education from the point of view of empowerment.     

Preoperative hair removal: a case report with implications for nursing

• ? Preoperative hair removal has been a practice since the beginning of this century. Research in the 1970s and 1980s provide support for the contention that the procedure is unnecessary for wound asepsis and may increase the rate of surgical site infections (Seropian & Reynolds, 1971; Hamilton et al., 1977; Cruse & Foord, 1980; Court-Brown, 1981; Alexander et al., 1983; Winfield, 1986; Fairclough et al., 1987). However, some hospitals have continued routine preoperative hair removal long after dissemination of recommendations against it. This begs the question, ‘Why is it that so often research findings are not applied in practice’.
• ? In Stroud v. General Hospital Corp. and Pollett (1993), a man died of sepsis resulting from cuts he gave himself after he was asked by a nurse, in complete violation of the hospital's preoperative skin preparation protocol, to clip hair from his abdomen. The court held the hospital liable for the nurse's negligent breach of its protocol. The case clearly supports findings in the literature that preoperative hair removal is potentially dangerous. It reinforces the importance of strict adherence to hospital protocols which have been put in place to protect patients' safety.

     

A clinical perspective on a pain neuroscience education approach to manual therapy

Abstract

In recent years, there has been an increased interest in pain neuroscience education (PNE) in physical therapy. There is growing evidence for the efficacy of PNE to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization in people struggling with pain. PNE teaches people in pain more about the biology and physiology of their pain experience including processes such as central sensitization, peripheral sensitization, allodynia, inhibition, facilitation, neuroplasticity and more. PNE’s neurobiological model often finds itself at odds with traditional biomedical models used in physical therapy. Traditional biomedical models, focusing on anatomy, pathoanatomy, and biomechanics have been shown to have limited efficacy in helping people understand their pain, especially chronic pain, and may in fact even increase a person’s pain experience by increasing fear-avoidance and pain catastrophization. An area of physical therapy where the biomedical model is used a lot is manual therapy. This contrast between PNE and manual therapy has seemingly polarized followers from each approach to see PNE as a ‘hands-off’ approach even having clinicians categorize patients as either in need of receiving PNE (with no hands-on), or hands-on with no PNE. In this paper, we explore the notion of PNE and manual therapy co-existing. PNE research has shown to have immediate effects of various clinical signs and symptoms associated with central sensitization. Using a model of sensitization (innocuous, noxious, and allodynia), we argue that PNE can be used in a manual therapy model, especially treating someone where the nervous system has become increasingly hypervigilant.

Level of Evidence: VII     

Bone wax as a cause of foreign body reaction after lumbar disc surgery: A case report

This report describes a 45-year-old patient who was admitted to the hospital with complaints of low-back pain, lower extremity weakness, and difficulty in walking for the previous 6 mo. The patient’s history revealed 2 lumbar-disc surgeries that were performed 1 y earlier. The patient underwent surgery at our hospital because of clinical symptoms and radiologic findings on magnetic resonance imaging. During the operation, 1×1×1 cm of bone wax that was compressing the dural sac and spinal root was extirpated from the surgical area. Bone wax use should be limited in spinal surgery because of the potential for compression and chronic inflammation.     

The clinical implementation of pain neuroscience education: A survey study

Pain neuroscience education (PNE) has gained considerable attention in research. Three systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. In the development of any new therapeutic approach, it is proposed that there are three stages: development, validation, and implementation. To date, the development and validation of PNE have been well-established. The third stage, implementation, however, lacks when it comes to PNE. The purpose of this study was to survey physical therapists (PT) on their experience and implementation of PNE, following a 15-hour PNE class. Upon development and validation of a PT-PNE survey, a random sample of PTs was invited to take the online survey. Two hundred and eighty-six PTs (female 56%) completed the PNE questionnaire. Ninety-one percent of PTs reported not being taught PNE in PT school. PT’s are applying PNE into clinical practice to a variety of patients, experience outcomes in line with the current best-evidence, but struggle establishing which patients are ideal for PNE. The same five patient characteristics associated with success were also associated with failure, albeit in a different ranking order. This finding highlight the need to further investigate the factors associated with success and failure of PNE.     

Postpartum sacral fracture presenting as lumbar radiculopathy: a case report

Although rare, sacral stress fractures may occur in pregnant women, and osteoporosis of pregnancy is a poorly understood entity. We present the case of a young, postpartum, recreational runner who developed low back pain (LBP) and radicular symptoms suggestive of L5 radiculopathy found to be secondary to sacral stress fracture. The patient had a good clinical outcome after several months and was able to resume her normal activities. This case illustrates that clinicians should have a high index of suspicion for sacral stress fracture in athletic pregnant or postpartum women presenting with LBP and/or lumbar radiculopathy. Also included are a brief review of osteoporosis in pregnancy and guidelines on the diagnosis and management of sacral stress fractures.     

腰椎椎体后缘离断症两种不同的手术方法疗效比较

目的探讨比较微创手术和开放手术治疗腰椎椎体后缘离断症的临床疗效。方法回顾性分析在2009年10月-2012年4月分别采用显微椎间盘镜下精确减压法(微创组)和全或半椎板开窗(开放组)治疗腰椎椎椎体后缘离断患者31例。其中,微创组14例,开放组17例,分别比较两组手术时间、术中出血量、术后引流量、住院时间,以及术前、术后VAS评分、JOA评分和ODI评及优良率。结果术后所有患者得到随访,随访时间12~28个月,平均(16.8±2.4)个月,微创组手术时间、术中出血量、术后引流量及住院时间均明显少于开放组,差异有显著性(P0.05)。两组术后3个月、末次随访疼痛VAS评分、JOA评分和ODI评分与术前比较差异均有显著性(P0.05),两组之间术后3个月、末次随访疼痛VAS评分、JOA评分和ODI评分差异无显著性(P0.05)。末次随访时采用改良Macnab标准评价临床效果,开放组优良率为94.1%,微创组优良率为92.9%,临床疗效相当。结论两组手术方法治疗腰椎椎体后缘离断症的治疗均能取得效果疗效,微创手术优势体现在早期,两种手术方式中期临床疗效相当。     

Benefits of Preoperative Education for Adult Elective Surgery Patients

Patient education is a major concern for perioperative nurses in an ambulatory surgery setting. It has proven difficult to develop formal preoperative teaching programs in this environment, but research has shown that preoperative education can improve patient outcomes and satisfaction with the surgical experience.Typical patient education consists of pamphlets that are given to the patient before surgery and verbal instructions from the physicians and nurses on the day of surgery. Ideally, preoperative patient education should begin in the surgeon's office, continue through preadmission testing, and be completed at admission. Having a well-designed preoperative education program enables perioperative nurses in ambulatory surgery centers to provide a thoughtful approach to perioperative teaching in a limited time. AORN J 90 (September 2009) 381-387. © AORN, Inc, 2009.     

Lavender Aromatherapy as a Nurse-Driven Intervention for Preoperative Anxiety

ObjectiveTo explore potential clinical applications, based on evidence and a nurse-driven test of change, of using lavender aromatherapy for preoperative anxiety as an intervention complementary to standard preoperative care.DesignA pre- versus postaromatherapy comparison using a visual analog scale (VAS).SettingThe preoperative department at a level 2 trauma hospital with 544 beds.ParticipantsForty-four surgical patients, including 29 female participants and 15 male participants.Intervention/MeasurementsParticipants reported their anxiety on a VAS before receiving a lavender aromatherapy inhaler. Anxiety scores were measured again after receiving the lavender aromatherapy and shortly before participants left the preoperative area for surgery. A pre–post comparison of the two VAS anxiety measurements before and after receiving the lavender aromatherapy was completed, analyzed, and is discussed.ResultsMean anxiety scores were calculated for the pre- and postaromatherapy groups. Forty-eight percent of female participants (n = 29) reported a decrease in their anxiety after receiving preoperative lavender aromatherapy. Female participants reported higher preoperative anxiety scores and a larger decrease in their mean anxiety scores after receiving lavender aromatherapy when compared to male participants.ConclusionThe use of a nurse-driven complementary intervention in the preoperative area was associated with a decrease in mean anxiety scores among female patients about to undergo elective surgery. However, cause and effect cannot be determined because of a lack of a control group and randomization. Opportunities exist with support from seasoned staff for nurses to incorporate safe, evidence-based complementary interventions into the current standard of care for preoperative anxiety.     

手术患者术前心理干预及临床效果评价

目的探讨妇科患者术前心理状况及心理干预的效果。方法对该院104例术前患者随机分为干预组和对照组,各52例,采用医学应对方式问卷(MCMQ)和焦虑自评量表(SAS)进行调查分析。结果干预组患者"面对"、"屈服"量表分值高于对照组,差异有统计学意义(P0.05);对照组患者的"避免"量表分略高于干预组,但差异无统计学意义(P=0.087);对照组患者"焦虑"总分高于干预组,且干预组和对照组焦虑等级构成比差异有统计学意义(P0.01);手术患者的"应对策略"与"焦虑情况"呈负相关,"避免与屈服"都与"焦虑"正相关。结论通过心理干预可帮助妇科患者改善应对方式,有效消除或缓解患者术前焦虑状况。     

Two-level percutaneous endoscopic lumbar discectomy for highly migrated upper lumbar disc herniation: A case report

BACKGROUND The technique of percutaneous endoscopic lumbar discectomy(PELD)as a transforaminal approach has been used to treat highly migrated lower lumbar disc herniations.However,due to the different anatomic characteristics of the upper lumbar spine,conventional transforaminal PELD may fail to remove the highly migrated upper lumbar disc nucleus pulposus.Therefore,the purpose of this study was to describe a novel surgical technique,two-level PELD,for the treatment of highly migrated upper lumbar disc herniations and to report its related clinical outcomes.CASE SUMMARY A 60-year-old male presented with a complaint of pain at his lower back and right lower limb.The patient received 3 mo of conservative treatments but the symptoms were not alleviated.Physical examination revealed a positive femoral nerve stretch test and a negative straight leg raise test for the right leg,and preoperative visual analog scale(VAS)score for the lower back was 6 points and for the right leg was 8 points.Magnetic resonance imaging(MRI)demonstrated L2-L3 disc herniation on the right side and the herniated nucleus pulposus migrated to the upper margin of L2 vertebral body.According to physical examination and imaging findings,surgery was the primary consideration.Therefore,the patient underwent surgical treatment with two-level PELD.The pain symptom was relieved and the VAS score for back and thigh pain was one point postoperatively.The patient was asymptomatic and follow-up MRI scan 1 year after operation revealed no residual nucleus pulposus.CONCLUSION Two-level PELD as a transforaminal approach can be a safe and effective procedure for highly migrated upper lumbar disc herniation.     

Outcomes and adverse events from physiotherapy functional restoration for lumbar disc herniation with associated radiculopathy

Purpose.?To report the outcomes and adverse events of people diagnosed with lumbar disc herniation with associated radiculopathy (LDHR) who were treated with a physiotherapy functional restoration programme.

Method.?Data on functional outcome (Oswestry score), work status, global rating of change, and adverse events were extracted from the files of all people with LDHR treated by three physiotherapists using functional restoration principles from 2001 to 2009.

Results.?Ninety-five participants were included. The Oswestry score reduced by a mean of 15.9 (95%% CI, 11.8–20.1) points between baseline and discharge following a mean (SD) of 8.7 (9.4) months of treatment. The proportion of participants working full-time increased from 37%% to 67%% between baseline and discharge (p < 0.001). Eighty per cent of participants reported overall improvement between baseline and discharge on the global rating of change scale (p < 0.001). Minor adverse events were reported by eight (8%%) participants, while one (1%%) participant developed adhesive capsulitis.

Conclusion.?People with LDHR who undertook a physiotherapy functional restoration programme achieved significant improvements in Oswestry disability scores, work status, and global rating of change, with few adverse events reported. A randomised controlled trial is warranted to determine the efficacy of functional restoration for people with this condition.     

A ganglion cyst causing lumbar radiculopathy in a baseball pitcher: a case report

This report describes a case of a professional baseball pitcher who developed acute left lumbar radicular symptoms after a baseball game and was subsequently sidelined for the rest of the season. Physical examination revealed depressed reflexes in the left posterior tibialis and left medial hamstring muscles, mild weakness in the left extensor hallucis longus, and positive dural tension signs. Magnetic resonance imaging demonstrated an ovoid mass at the L4-L5 level, causing compression of the dura. Surgical resection of the mass resulted in resolution of his symptoms. Pathology revealed that the mass was a ganglion cyst. A ganglion cyst is a rare cause of lumbar radiculopathy and should be considered in the differential diagnosis if a patient with lumbar radiculopathy fails to respond to conservative treatment.     

Brain somatic representation of phantom and intact limb: a fMRI study case report.

Reports on phantom limb patients concerning neuronal reorganization using non-invasive methods have focused mainly on the cortical regions and suggest the presence of pain as the cause of this reorganization. The phantom limb, however, includes other somatic and motor sensations other than pain. Here we describe the results of non-painful stimulation in cortical and subcortical lateralization and reorganization and also examine the involvement of subcortical structures in phantom limb telescoping perception. We describe an enlarged contralateral cortical representation of the stump, a cortical and thalamic bilateral representation of the remaining leg, and a neuronal correlate of a telescoping perception of the phantom limb. The missing leg produces an enlarged cortical representation due to abnormal information and the remaining leg has a bilateral SII representation, which could be related to new, compensatory functions. The telescoping perception of a phantom limb by the stimulation of misallocation points was correlated with lenticular nuclei, thalamic and cingulate gyrus activation.We therefore propose that the reorganization concept of a phantom limb, applied mainly to the cortex, must extend to the thalamic and the somatosensory and motor systems (pathways and relay nuclei).