Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery.

OBJECTIVES: To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway. DESIGN: A cross-sectional, qualitative study with an interpretive descriptive design. SETTING: Academic and non-academic hospital setting in Belgium. PARTICIPANTS: 31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed. RESULTS: Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS. CONCLUSIONS: This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness. TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov (NCT03427294).

Best practice rehabilitation pathway for the management of single and double-level lumbar fusion surgery: a modified Delphi Study.

BACKGROUND: There is limited evidence to guide the rehabilitation of patients following single or double-level lumbar fusion surgery (LFS). This is reflected in extensive variability in current rehabilitation regimes and subsequent low clinical success rates, which urges a call for a consensus rehabilitation pathway. AIM: To establish consensus on the optimal pre-, peri- and postoperative rehabilitation of LFS. DESIGN: A modified Delphi Study. SETTING: Belgium and the Netherlands. POPULATION: A multidisciplinary panel of 31 experts in the field of LFS and rehabilitation participated. Nine patients validated the consensus pathway. METHODS: A three-round online Delphi questionnaire was followed by an in-person consensus meeting. In each round, experts could suggest new statements, and received group summary statistics and feedback for reconsidered statements. Consensus threshold was set at ≥75% agreement. The resulting rehabilitation pathway was validated by patients through an online questionnaire and subsequent in-person focus group. RESULTS: A total of 31 experts participated in the first online round, with 27 (87%) completing all online rounds, and 17 (55%) attending the in-person consensus meeting. Consensus was reached on 122 statements relating to pre-, peri- and postoperative rehabilitation of LFS, and validated by patients. Key components of the rehabilitation pathway included prehabilitation, education, physiotherapy in every phase, early postoperative mobilization, and little movement restrictions. Patients emphasized the need for support during the return-to-work process. CONCLUSIONS: This process resulted in 122 expert-consensus statements on best practice rehabilitation for managing LFS, validated by patients. CLINICAL REHABILITATION IMPACT: The proposed rehabilitation pathway can serve as guidance to support clinicians, reduce practice variability, and subsequently improve clinical outcomes after LFS.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis.

PURPOSE: To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis. METHODS: Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE. RESULTS: In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies). CONCLUSION: There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

Applying a knowledge translation framework for triaging low back pain and radicular pain at an emergency department: an iterative process within an uncontrolled before-and-after design.

BACKGROUND: Diagnostic imaging for low back pain (LBP) without any indication of a serious underlying cause does not improve patient outcomes. However, there is still overuse of imaging, especially at emergency departments (EDs). Although evidence-based guidelines for LBP and radicular pain management exist, a protocol for use at the ED in the Belgian University Hospitals Leuven was not available, resulting in high practice variation. The present paper aims to describe the process from protocol development to the iterative implementation approach and explore how it has influenced practice. METHODS: In accordance with a modified 'knowledge-to-action' framework, five steps took place within the iterative bottom-up implementation process: (1) identification of the situation that requires the implementation of evidence based recommendations, (2) context analysis, (3) development of an implementation plan, (4) evaluation and (5) sustainability of the implemented practice recommendations. Two potential barriers were identified: the high turnover of attending specialists at the ED and patients' and general practicioners' expectations that might overrule the protocol. These were tackled by educational sessions for staff, patient brochures, an information campaign and symposium for general practitioners. RESULTS: The rate of imaging of the lumbar spine decreased from over 25% of patients to 15.0%-16.4% for CT scans and 19.0%-21.8% for X-rays after implementation, but started to fluctuate again after 3 years. After introducing a compulsory e-learning before rotation and catchy posters in the ED staff rooms, rates decreased to 14.0%-14.6% for CT scan use and 12.7-13.5% for X-ray use. CONCLUSIONS: Implementation of a new protocol in a tertiary hospital ED with high turn over of rotating trainees is a challenge and requires ongoing efforts to ensure sustainability. Rates of imaging represent an indirect though useful indicator. We have demonstrated that it is possible to implement a protocol that includes demedicalisation in an ED environment and to observe changes in indicator results.

Evaluation of feedback reduction techniques in hearing aids based on physical performance measures.

This paper presents a physical evaluation of four feedback cancellation techniques in commercial hearing aids and two implementations of a recently developed feedback cancellation algorithm. Based on physical measures for detecting instability, oscillations and distortion, three performance aspects were measured: 1) the added stable gain compared to the hearing aid operating without feedback reduction for white noise as well as for spectrally colored input signals in two static acoustic conditions, 2) the amount of feedback, oscillations and distortion at gain values below the maximum stable gain, 3) the ability to track feedback path changes. Added stable gains between 3 dB and 26 dB were identified. Five of the six techniques achieve worse feedback reduction for a tonal opera input signal than for a speech input signal. Preventing the feedback canceller to drift away from an initial feedback path measurement results in improved performance for tonal signals at the expense of a worse feedback reduction in the acoustic conditions that differ from the condition for which the initialization was performed, as well as a worse tracking of feedback path changes. Repeated measures indicated that the reproducibility of the test set-up is crucial, in particular when the hearing aid operates close to instability.

Multicenter evaluation of signal enhancement algorithms for hearing aids.

In the framework of the European HearCom project, promising signal enhancement algorithms were developed and evaluated for future use in hearing instruments. To assess the algorithms' performance, five of the algorithms were selected and implemented on a common real-time hardware/software platform. Four test centers in Belgium, The Netherlands, Germany, and Switzerland perceptually evaluated the algorithms. Listening tests were performed with large numbers of normal-hearing and hearing-impaired subjects. Three perceptual measures were used: speech reception threshold (SRT), listening effort scaling, and preference rating. Tests were carried out in two types of rooms. Speech was presented in multitalker babble arriving from one or three loudspeakers. In a pseudo-diffuse noise scenario, only one algorithm, the spatially preprocessed speech-distortion-weighted multi-channel Wiener filtering, provided a SRT improvement relative to the unprocessed condition. Despite the general lack of improvement in SRT, some algorithms were preferred over the unprocessed condition at all tested signal-to-noise ratios (SNRs). These effects were found across different subject groups and test sites. The listening effort scores were less consistent over test sites. For the algorithms that did not affect speech intelligibility, a reduction in listening effort was observed at 0 dB SNR.

Speech understanding in background noise with the two-microphone adaptive beamformer BEAM in the Nucleus Freedom Cochlear Implant System.

OBJECTIVE: This paper evaluates the benefit of the two-microphone adaptive beamformer BEAM in the Nucleus Freedom cochlear implant (CI) system for speech understanding in background noise by CI users. DESIGN: A double-blind evaluation of the two-microphone adaptive beamformer BEAM and a hardware directional microphone was carried out with five adult Nucleus CI users. The test procedure consisted of a pre- and post-test in the lab and a 2-wk trial period at home. In the pre- and post-test, the speech reception threshold (SRT) with sentences and the percentage correct phoneme scores for CVC words were measured in quiet and background noise at different signal-to-noise ratios. Performance was assessed for two different noise configurations (with a single noise source and with three noise sources) and two different noise materials (stationary speech-weighted noise and multitalker babble). During the 2-wk trial period at home, the CI users evaluated the noise reduction performance in different listening conditions by means of the SSQ questionnaire. In addition to the perceptual evaluation, the noise reduction performance of the beamformer was measured physically as a function of the direction of the noise source. RESULTS: Significant improvements of both the SRT in noise (average improvement of 5-16 dB) and the percentage correct phoneme scores (average improvement of 10-41%) were observed with BEAM compared to the standard hardware directional microphone. In addition, the SSQ questionnaire and subjective evaluation in controlled and real-life scenarios suggested a possible preference for the beamformer in noisy environments. CONCLUSIONS: The evaluation demonstrates that the adaptive noise reduction algorithm BEAM in the Nucleus Freedom CI-system may significantly increase the speech perception by cochlear implantees in noisy listening conditions. This is the first monolateral (adaptive) noise reduction strategy actually implemented in a mainstream commercial CI.