Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?

Background contextSystematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this “at risk” population, has been suggested as a possible solution.PurposeTo compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery.Study design/settingA prospective cohort study of chronic disabling occupational lumbar disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program.Patient sampleA consecutive cohort of 564 patients with prerehabilitation surgery completed a functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, N=331) and nonfusion lumbar spine surgery (NF group, N=233). An unoperated comparison group was matched for length of disability (U group, N=349).Outcome measuresValidated patient-reported measures of pain, disability, and depression were administered pre- and postrehabilitation. Socioeconomic outcomes were collected via a structured 1-year “after” interview.MethodsAll patients completed an intensive, medically supervised functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. The writing of this article was supported in part by National Institutes of Health Grant 1K05-MH-71892; no conflicts of interest are noted among the authors.ResultsThe F group had a longer length of disability compared with the NF and U groups (M=31.6, 21.7, and 25.9 months, respectively, p<.001). There were relatively few statistically significant differences for any socioeconomically relevant outcome among groups, with virtually identical postrehabilitation return-to-work (F=81%, NF=84%, U=85%, p=.409). The groups differed significantly after surgery on diagnosis of major depressive disorder and opioid dependence disorder as well as patient-reported depressive symptoms and pain intensity prerehabilitation. However, no significant differences in patient-reported outcomes were found postrehabilitation. Prerehabilitation opioid dependence disorder significantly predicted lower rates of work return and work retention as well as higher rates of treatment-seeking behavior. Higher levels of prerehabilitation perceived disability and depressive symptoms were significant risk factors for poorer work return and retention outcomes.ConclusionsLumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable to CDOLD patients treated nonoperatively. This study suggests that surgeons have the opportunity to improve lumbar surgery outcomes in the WC system, even for complex fusion CDOLD patients with multiple prior operations, if they control postoperative opioid dependence and prevent an excessive length of disability. Through early referral of patients (who fail to respond to usual postoperative care) to interdisciplinary rehabilitation, the surgeon determining this continuum of care may accelerate recovery and achieve socioeconomic outcomes of relevance to the patient and WC jurisdiction through the combination of surgery and postoperative rehabilitation.     

VO2max in patients with chronic pain: The effect of a 4-week rehabilitation program

BackgroundIn patients with chronic pain, aerobic deconditioning can explain part of observed disability and disadvantage. The objective of the present study was to assess the change in VO₂max after a four-week exercise rehabilitation programme in this population.MethodsIn a prospective study, 121 patients underwent a cycle ergometer exercise tolerance test with VO₂max measurement before and after a four-week exercise rehabilitation programme (which included aerobic training, muscle strengthening, occupational therapy and stretching).ResultsWe observed a statistically significant increase in VO₂max (P = 0.03) and an improvement in the patients’ distribution according to the Shvartz fitness classification after rehabilitation.DiscussionThe four-week exercise rehabilitation program was associated with an improvement in aerobic capacities in patients with chronic pain. However, in all but one of the 121 patients, the VO₂max value at the end of the program was below average for gender and age. Maintenance of aerobic training after the end of a rehabilitation programme is essential.     

The addition of respiratory muscle strength training to facilitate swallow and pulmonary rehabilitation following massive tissue loss and severe deconditioning: A case series

IntroductionImpaired respiratory and swallow function in patients with intensive care unit–acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation.AimThe aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss.MethodsCase 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale [PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale [NZSS]), and functional diet (Functional Oral Intake Scale [FOIS]) via endoscopy.Results/discussionAt baseline, the PEF score of case 1 was 41% (predicted age–height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively.ConclusionThe addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required.     

A realist review of the effective implementation of the ICU Liberation Bundle in the paediatric intensive care unit setting

ObjectiveThe objective of this study was to produce an evidence base of what works, for whom, and in what context when implementing the ICU Liberation Bundle into the paediatric intensive care unit (PICU).Review method usedThis is a realist review (a review that considers what works, for whom, and in what context) of contemporary international literature.Data sourcesData were collected via electronic searches of CINAHL, PubMed, EMBASE and MEDLINE, Google Scholar, and Web of Science for articles published before October 2020.Review methodAn initial scoping search identified the underpinning theory of the implementation of the ICU Liberation Bundle (a multifactor intervention aimed at improving patient outcomes) which was mapped onto the Consolidated Framework for Implementation Research (CFIR). We identified 547 unique citations; 12 full-text papers were included that reported eight studies. Data were extracted and mapped to the CFIR domains.ResultsData mapped to all CFIR domains. Characteristics of individuals included involvement of key stakeholders, champions, and parents and understanding of staff attitudes and perceptions of the intervention, and all bedside staff members were involved and given training. Within the inner setting, understanding of unit culture, ensuring effective support systems in place, knowledge of the baseline, and leadership support, and buy-in were important. Culture of family-centred care and alignment of the intervention to national guidelines related to the outer setting. Intervention characteristics included the number and timings of interventions, de-escalation rounding checklists, the use of age-appropriate and validated assessment tools, and local policies for the bundle. The process included set training program, senior unit/hospital team consultation on all processes, continual audit adherence to the bundle and feedback, and celebration of successes.ConclusionsThis novel realist review of the literature identified that successful implementation of the ICU Liberation Bundle into PICU settings involves the following: (i) a thorough understanding of the PICU context, including baseline metrics, resources, and staff attitudes; (ii) using contextual information to adapt the intervention elements to ensure fit; and (iii) both clinical effectiveness and implementation outcomes must be measured.Registration of review: PROSPERO 2020 CRD42020211944.     

Disuse and deconditioning in chronic low back pain: concepts and hypotheses on contributing mechanisms.

For years enhancement of a patient's level of physical fitness has been an important goal in rehabilitation treatment in chronic low back pain (CLBP), based on the hypothesis that physical deconditioning contributes to the chronicity of low back pain. However, whether this hypothesis in CLBP holds is not clear. In this paper, possible mechanisms that contribute to the development of physical deconditioning in CLBP, such as avoidance behaviour and suppressive behaviour, are discussed. The presence of both deconditioning-related physiological changes, such as muscle atrophy, changes in metabolism, osteoporosis and obesity as well as deconditioning related functional changes, such as a decrease in cardiovascular capacity, a decrease in muscle strength and impaired motor control in patients with CLBP are discussed. Results of studies on the level of physical activities in daily life (PAL) and the level of physical fitness in patients with CLBP compared to healthy controls were reviewed. In studies on PAL results that were either lower or comparable to healthy subjects were found. The presence of disuse (i.e., a decrease in the level of physical activities in daily life) in patients with CLBP was not confirmed. The inconclusive findings in the papers reviewed may partly be explained by different measurement methods used in research on PAL in chronic pain. The level of physical fitness of CLBP patients also appeared to be lower or comparable to the fitness level of healthy persons. A discriminating factor between fit and unfit patients with back pain may be the fact that fit persons more frequently are still employed, and as such may be involved more in physical activity. Lastly some suggestions are made for further research in the field of disuse and deconditioning in CLBP.