(Cost-)effectiveness of personalised multimodal physiotherapy compared to surgery in patients with cervical radiculopathy: A systematic review.

RATIONALE: Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking. AIM/OBJECTIVES: To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy. METHODS: PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported. CONCLUSION: Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.

The impact of being overweight or obese on 12 month clinical recovery in patients following lumbar microdiscectomy for radiculopathy.

BACKGROUND CONTEXT: The proportion of patients who undergo lumbar microdiscectomy due to lumbar radiculopathy who are also overweight or obese is high. However, whether high body mass index (BMI) affects clinical outcomes is not well-studied. PURPOSE: To investigate the difference in the clinical course between normal weight, overweight, and obese patients with radiculopathy who underwent lumbar microdiscectomy followed by physical therapy and to evaluate whether high BMI is associated with poor recovery. STUDY DESIGN/SETTING: A prospective cohort study with a 12-month follow-up was conducted in a multidisciplinary clinic. PATIENT SAMPLE: We included 583 patients (median [IQR] age: 45 [35-52] years; 41% female) with clinical signs and symptoms of lumbar radiculopathy, consistent with magnetic resonance imaging findings, who underwent microdiscectomy followed by postoperative physical therapy. OUTCOME MEASURES: Outcomes were leg pain and back pain intensity measured with a visual analogue scale, disability measured with the Roland Morris Disability Questionnaire at 3 and 12-month follow-ups, and complications. METHODS: Patients were classified as being normal weight (46.9%), overweight (38.4%), or obese (14.7%). A linear mixed-effects model was used to assess the difference in the clinical course of pain and disability between the three BMI categories. The association between BMI and outcomes was evaluated using univariable and multivariable logistic regression analyses. RESULTS: All three patient groups experienced a significant improvement in leg pain, back pain, and disability over 3 and 12-month follow-up. Patients who were overweight, obese, or normal weight experienced comparable leg pain (p=.14) and disability (p=.06) over the clinical course (p=.14); however, obese patients experienced higher back pain (MD=-6.81 [95%CI: -13.50 to -0.14]; p=.03). The difference in back pain scores was not clinically relevant. CONCLUSIONS: In the first year following lumbar microdiscectomy, patients demonstrated clinical improvements and complications that were unrelated to their preoperative BMI.

Variability in recovery following microdiscectomy and postoperative physiotherapy for lumbar radiculopathy: A latent class trajectory analysis.

OBJECTIVES: The clinical course of lumbar radiculopathy following microdiscectomy and post-operative physiotherapy varies substantially. No prior studies assessed this variability by deriving outcome trajectories. The primary aims of this study were to evaluate the variability in long-term recovery after lumbar microdiscectomy followed by post-operative physiotherapy and to identify outcome trajectories. The secondary aim was to assess whether demographic, clinical characteristics and patient-reported outcome measures routinely collected at baseline could predict poor outcome trajectories. METHODS: We conducted a prospective cohort study with a 24-month follow-up. We included 479 patients with clinical signs and symptoms of lumbar radiculopathy confirmed by Magnetic Resonance Imaging findings, who underwent microdiscectomy and post-operative physiotherapy. Outcomes were leg pain and back pain measured with Visual Analogue Scales, and disability measured with the Roland-Morris Disability Questionnaire. Descriptive statistics were performed to present the average and the individual clinical course. A latent class trajectory analysis was conducted to identify leg pain, back pain, and disability outcome trajectories. The best number of clusters was determined using the Bayesian Information Criterion, Akaike's information criteria, entropy, and overall interpretability. Prediction models for poor outcome trajectories were assessed using multivariable logistic regression analyses. RESULTS: Several outcome trajectories were identified. Most patients were assigned to the 'large improvement' trajectory (leg pain: 79.3%; back pain: 70.2%; disability: 59.5% of patients). Smaller proportions of patients were assigned to the 'moderate improvement' trajectory (leg pain: 7.9%; back pain: 10.6%; disability: 20.7% of patients), the 'minimal improvement' trajectory (leg pain: 4.9%, back pain: 6.7%, disability: 16.3% of patients) and the 'relapse' trajectory (leg pain: 7.9%; back pain: 12.5%; disability: 3.5%). Approximately one-third of patients (32.6%) belonged to one or more than one poor outcome trajectory. Patients with previous treatment (prior back surgery, injection therapy, and medication use) and those who had higher baseline pain and disability scores were more likely to belong to the poor outcome trajectories in comparison to the large improvement trajectories in back pain, leg pain and disability, and the moderate improvement trajectory in disability. The explained variance (Nagelkerke R2) of the prediction models ranged from 0.06 to 0.13 and the discriminative ability (Area Under the Curve) from 0.66 to 0.73. CONCLUSION: The clinical course of lumbar radiculopathy varied following microdiscectomy and post-operative physiotherapy, and several outcome trajectories could be identified. Although most patients were allocated to favorable trajectories, one in three patients was assigned to one or more poor outcome trajectories following microdiscectomy and post-operative physiotherapy for lumbar radiculopathy. Routinely gathered data were unable to predict the poor outcome trajectories accurately. Prior to surgery, clinicians should discuss the high variability and the distinctive subgroups that are present in the clinical course with their patients.

A Clinical Journey Mobile Health App for Perioperative Patients: Cross-sectional Study.

BACKGROUND: Mobile eHealth apps are important tools in personal health care management. The Patient Journey app was developed to inform patients with musculoskeletal disorders during their perioperative period. The app contains timely information, video exercises, and functional tasks. Although the Patient Journey app and other health apps are widely used, little research is available on how patients appreciate these apps. OBJECTIVE: The primary aim of this study was to evaluate the user-friendliness of the Patient Journey app in terms of its usability and the attitudes of users toward the app. The secondary aim was to evaluate positive and negative user experiences. METHODS: A web-based questionnaire was sent to 2114 patients scheduled for surgery for a musculoskeletal disorder. Primary outcomes were usability (measured with the System Usability Scale) and user attitudes regarding the Patient Journey app (assessed with the second part of the eHealth Impact Questionnaire). The secondary outcomes were evaluated with multiple choice questions and open-ended questions, which were analyzed via inductive thematic content analyses. RESULTS: Of the 940 patients who responded, 526 used the Patient Journey app. The usability of the app was high (System Usability Scale: median 85.0, IQR 72.5-92.5), and users had a positive attitude toward the Information and Presentation provided via the app (eHealth Impact Questionnaire: median 78.0, IQR 68.8-84.4). The app did not adequately improve the users' confidence in discussing health with others (eHealth Impact Questionnaire: median 63.9, IQR 50.0-75.0) or motivation to manage health (eHealth Impact Questionnaire: median 61.1, IQR 55.6-72.2). Three core themes emerged regarding positive and negative user experiences: (1) content and information, (2) expectations and experiences, and (3) technical performance. Users experienced timely information and instructions positively and found that the app prepared and guided them optimally through the perioperative period. Negative user experiences were overly optimistic information, scarcely presented information about pain (medication), lack of reference data, insufficient information regarding clinical course deviations and complications, and lack of interaction with clinicians. CONCLUSIONS: The Patient Journey app is a usable, informative, and presentable tool to inform patients with musculoskeletal disorders during their perioperative period. The qualitative analyses identified aspects that can further improve the user experiences of the app.

Diagnostic accuracy of patient interview items and clinical tests for cervical radiculopathy.

OBJECTIVE: To determine the diagnostic accuracy of patient interview items and clinical tests to diagnose cervical radiculopathy. DESIGN: A prospective diagnostic accuracy study. PARTICIPANTS: Consecutive patients (N=134) with a suspicion of cervical radiculopathy were included. A medical specialist made the diagnosis of cervical radiculopathy based on the patient's clinical presentation and corresponding Magnetic Resonance Imaging findings. Participants completed a list of patient interview items and the clinical tests were performed by a physiotherapist. MAIN OUTCOME MEASURES: Diagnostic accuracy was determined in terms of sensitivity, specificity, and positive (+LR) and negative likelihood ratios (-LR). Sensitivity and specificity values ≥0.80 were considered high. We considered +LR≥5 and -LR≤0.20 moderate, and +LR≥10 and -LR≤0.10 high. RESULTS: The history items 'arm pain worse than neck pain', 'provocation of symptoms when ironing', 'reduction of symptoms by walking with your hand in your pocket', the Spurling test and the presence of reduced reflexes showed high specificity and are therefore useful to increase the probability of cervical radiculopathy when positive. The presence of 'paraesthesia' and 'paraesthesia and/or numbness' showed high sensitivity, indicating that the absence of these patient interview items decreases the probability of cervical radiculopathy. Although most of these items had potentially relevant likelihood ratios, none showed moderate or high likelihood ratios. CONCLUSIONS: Several patient interview items, the Spurling test and reduced reflexes are useful to assist in the diagnosis of cervical radiculopathy. Because there is no gold standard for cervical radiculopathy, caution is required to not over-interpret diagnostic accuracy values.

Baseline Patient Characteristics Commonly Captured Before Surgery Do Not Accurately Predict Long-Term Outcomes of Lumbar Microdiscectomy Followed by Physiotherapy.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To develop and internally validate prognostic models based on commonly collected preoperative data for good and poor outcomes of lumbar microdiscectomy followed by physiotherapy. SUMMARY OF BACKGROUND DATA: Lumbar microdiscectomy followed by physiotherapy is a common intervention for lumbar radiculopathy. Postoperatively, a considerable percentage of people continues to experience pain and disability. Prognostic models for recovery are scarce. METHODS: We included 298 patients with lumbar radiculopathy who underwent microdiscectomy followed by physiotherapy. Primary outcomes were recovery and secondary outcomes were pain and disability at 12 months follow-up. Potential prognostic factors were selected from sociodemographic and biomedical data commonly captured preoperatively. The association between baseline characteristics and outcomes was evaluated using multivariable logistic regression analyses. RESULTS: At 12 months follow-up, 75.8% of the participants met the criterion for recovery. Variables in the model for good recovery included: younger age, leg pain greater than back pain, high level of disability, and a disc herniation at another level than L3-L4. The model for poor recovery included: lower educational level, prior back surgery, and disc herniation at L3-L4. Following internal validation, the explained variance (Nagelkerke R) and area under the curve for both models were poor (≤0.02 and ≤0.60, respectively). The discriminative ability of the models for disability and pain were also poor. CONCLUSION: The outcome of microdiscectomy followed by postoperative physiotherapy cannot be predicted accurately by commonly captured preoperative sociodemographic and biomedical factors. The potential value of other biomedical, personal, and external factors should be further investigated. LEVEL OF EVIDENCE: 3.

Clinical course and prognostic models for the conservative management of cervical radiculopathy: a prospective cohort study.

PURPOSE: To describe the clinical course and develop prognostic models for poor recovery in patients with cervical radiculopathy who are managed conservatively. METHODS: Sixty-one consecutive adults with cervical radiculopathy who were referred for conservative management were included in a prospective cohort study, with 6- and 12-month follow-up assessments. Exclusion criteria were the presence of known serious pathology or spinal surgery in the past. Outcome measures were perceived recovery, neck pain intensity and disability level. Multiple imputation analyses were performed for missing values. Prognostic models were developed using multivariable logistic regression analyses, with bootstrapping techniques for internal validation. RESULTS: About 55% of participants reported to be recovered at 6 and 12 months. All multivariable models contained 2 baseline predictors. Longer symptoms duration increased the risk of poor perceived recovery, whereas the presence of paresthesia decreased this risk. A higher neck pain intensity and a longer duration of symptoms increased the risk of poor relief of neck pain. A higher disability score increased the risk of poor relief of disability, and larger active range of rotation toward the affected side decreased this risk. Following bootstrapping, the explained variance of the models varied between 0.22 and 0.30, and the median area under the curve varied between 0.75 and 0.79. CONCLUSIONS: The clinical course of cervical radiculopathy appears to be long, with most of the reduction in symptoms occurring within the first 6 months. All prognostic models showed an adequate predictive performance with modest diagnostic accuracy and explained variance. These slides can be retrieved under Electronic Supplementary Material.

Spatiotemporal pattern of neuroinflammation after impact-acceleration closed head injury in the rat.

Inflammatory processes have been implicated in the pathogenesis of traumatic brain damage. We analyzed the spatiotemporal expression pattern of the proinflammatory key molecules: interleukin-1beta, interleukin-6, tumor necrosis factor-alpha, and inducible nitric oxide synthase in a rat closed head injury (CHI) paradigm. 51 rats were used for RT-PCR analysis after CHI, and 18 for immunocytochemistry. We found an early upregulation of IL-1beta, IL-6, and TNF-alpha mRNA between 1h and 7h after injury; the expression of iNOS mRNA only revealed a significant increase at 4h. After 24h, the expression decreased towards baseline levels, and remained low until 7d after injury. Immunocytochemically, IL-1beta induction was localized to ramified microglia in areas surrounding the primary impact place as well as deeper brain structures. Our study shows rapid induction of inflammatory gene expression that exceeds by far the primary impact site and might therefore contribute to tissue damage at remote sites.

A role for the cerebellum in motor speech planning: evidence from foreign accent syndrome.

A 3 year follow-up study was performed in a patient with foreign accent syndrome (FAS) as the sole cognitive manifestation of a left fronto-parietal stroke. The hypothesis of involvement of the right cerebellum in this motor speech planning disorder was investigated by means of functional neuroimaging (SPECT) and neurobehavioral assessments. Based on the close parallelism between the evolution of FAS symptoms and the perfusional changes in the right cerebellum, it is argued that FAS may result from a disruption of a close functional interplay between the supra- and infratentorial speech centers involved in motor speech planning.

Pentobarbital fails to reduce cerebral oxygen consumption early after non-hemorrhagic closed head injury in rats.

It is unknown whether barbiturates suppress cerebral oxygen metabolism after cerebral trauma as they do in normal individuals. We evaluated the influence of pentobarbital on cerebral oxygen handling of normal rats and rats subjected to non-hemorrhagic closed head injury (CHI). Oxygen delivery was assessed by measuring cerebral perfusion and oxygen extraction, enabling the calculation of cerebral metabolic rate of oxygen (CMRO2). Mitochondrial function was assessed by studying changes in the oxidized cytochrome oxidase concentration. CHI caused changes in both systemic and cerebral hemodynamics. Cerebral blood flow was reduced to 66% of its control value, but the cerebral metabolic rate of oxygen remained unchanged. Pentobarbital administration induced a significant lowering of the cerebral oxygen consumption in normal rats associated with a secondary decrease in cerebral perfusion. In rats subjected to CHI, pentobarbital was unable to lower the cerebral metabolic demand and did not cause a further decrease in perfusion. Pentobarbital was unable to significantly modulate mitochondrial function in traumatized rats, whereas it exerted this effect in all control animals. We therefore conclude that, in rats subjected to CHI, pentobarbital is unable to perform its beneficial effects on the cerebral metabolism.

Continuous measurement of intracranial pressure in awake rats after experimental closed head injury.

The present study validates a method for continuous measurement of intracranial pressure (ICP) in freely moving rats after experimental induction of impact-acceleration injury. Rats subjected to either mild or moderate trauma were individually placed in a Bas-Ratturn system, equipped with a sensor that synchronously turns the cage in response to the locomotor activity of the animal. In this way correct probe positioning is permanently assured and damage due to coiling is avoided. The evolution of ICP and mean arterial blood pressure (MABP) in injured rats was compared with that of a non-traumatized sham group. Since the animals regained consciousness after surgery, interference of anaesthesia on these sensitive parameters should be minimised. The results showed that immediately after induction of neurotrauma, ICP was significantly higher in traumatized rats (sham: 7.7 +/- 0.5 mmHg; mild trauma: 10.4 +/- 0.7 mmHg; moderate trauma: 14.9 +/- 2.4 mmHg; P<0.05). Regression analysis showed a stable ICP up to 3 h post-insult for all three conditions. From 4 h onwards till the end of the experiment at 10 h post-insult, a significant increase in ICP was seen for sham-operated and mildly traumatized rats (16.1 +/- 3.4 and 30.5 +/- 6.9 mmHg, respectively; P<0.05), but not for moderately traumatized rats (47.3 +/- 11.9 mmHg). The method allows observation of ICP for a critical period up to 3 h. As such the method can be regarded as clinically relevant to study early pathological aspects of intracranial hypertension and to define a therapeutic window for pharmacological intervention after traumatic brain injury (TBI).

Ultrasound agents may open the blood-brain barrier in rats and aggravate pathologic consequences of experimental head trauma.

Unilateral intracarotid injection of contrast agents may considerably destabilize the blood-brain barrier in rats. This leads to vasogenic edema in the ipsilateral hemisphere. Mortality and extravasation increased significantly when administration of these ultrasound contrast agents was followed by mild traumatic brain injury. Direct administration to the cerebral circulation is, therefore, indicative for edema-related pathology and may amplify the consequences of experimental neurotrauma.

Comparison of intracranial pressure measured in the cerebral cortex and the cerebellum of the rat.

In this study, we evaluated the accuracy of intracranial pressure (ICP) measurement in rats by insertion of a miniature ICP probe in the parenchyma of the cerebellum. A comparison was made between the ICP values measured simultaneously in the parenchyma of the cerebral cortex and the cerebellum. In order to obtain a wide range of ICP, animals were subjected to a severe closed head injury (CHI), a moderate CHI or to a sham operation. ICP values ranged from 0.8 to 43.9 mmHg. After 15 min stabilisation the first measurement was taken and followed by a second measurement 25 min after onset to allow comparison of ICP changes at the two implantation sites. Linear regression analysis showed a highly significant correlation at 15 min: Y = 0.919X + 0.655 (R(2) = 0.977), and at 25 min: Y = 0.931X + 0.698 (R(2) = 0.976). The differences in ICP measurement between cerebellar and cerebral site were not significantly different from zero at both time points. Altman-Bland plots showed that the difference in ICP readings between the two locations could differ maximally by 5.3 mmHg. The largest differences were detected when high ICP values were recorded. We conclude that in rats the ICP measurement in the cerebellum is comparable to the ICP measurement in the cerebral cortex. The cerebellar ICP can be used as a valuable alternative during experimental procedures.