Leg pain and psychological variables predict outcome 2-3 years after lumbar fusion surgery.

Prediction studies testing a thorough range of psychological variables in addition to demographic, work-related and clinical variables are lacking in lumbar fusion surgery research. This prospective cohort study aimed at examining predictions of functional disability, back pain and health-related quality of life (HRQOL) 2-3 years after lumbar fusion by regressing nonlinear relations in a multivariate predictive model of pre-surgical variables. Before and 2-3 years after lumbar fusion surgery, patients completed measures investigating demographics, work-related variables, clinical variables, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, mental health and pain coping. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate predictor variables and address predictive model validity. The most parsimonious and stable subset of pre-surgical predictor variables explained 41.6, 36.0 and 25.6% of the variance in functional disability, back pain intensity and HRQOL 2-3 years after lumbar fusion. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical straight leg raise significantly predicted back pain. Post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL. For the median dichotomised classification of functional disability, back pain intensity and HRQOL levels 2-3 years post-surgery, the discriminative ability of the prediction models was of good quality. The results demonstrate the importance of pre-surgical psychological factors, leg pain intensity, straight leg raise and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL-related outcomes.

Evidence-based practice: attitudes, knowledge and behaviour among allied health care professionals.

OBJECTIVE: To explore dieticians', occupational therapists' and physical therapists' attitudes, beliefs, knowledge and behaviour concerning evidence-based practice within a university hospital setting. DESIGN: Cross-sectional survey. SETTING: University hospital. PARTICIPANTS: All dieticians, occupational therapists and physical therapists employed at a Swedish university hospital (n = 306) of whom 227 (74%) responded. MAIN OUTCOME MEASURES: Attitudes towards, perceived benefits and limitations of evidence-based practice, use and understanding of clinical practice guidelines, availability of resources to access information and skills in using these resources. RESULTS: Findings showed positive attitudes towards evidence-based practice and the use of evidence to support clinical decision-making. It was seen as necessary. Literature and research findings were perceived as useful in clinical practice. The majority indicated having the necessary skills to be able to interpret and understand the evidence, and that clinical practice guidelines were available and used. Evidence-based practice was not perceived as taking into account the patient preferences. Lack of time was perceived as the major barrier to evidence-based practice. CONCLUSIONS: The prerequisites for evidence-based practice were assessed as good, but ways to make evidence-based practice time efficient, easy to access and relevant to clinical practice need to be continuously supported at the management level, so that research evidence becomes linked to work-flow in a way that does not adversely affect productivity and the flow of patients.

Patients' experience post-lumbar fusion regarding back problems, recovery and expectations in terms of the International Classification of Functioning, Disability and Health.

PURPOSE: To describe within the context of the International Classification of Functioning, Disability and Health (ICF), patient's experiences post-lumber fusion regarding back problems, recovery and expectations of rehabilitation and to contrast with the content of outcome measures and the ICF low back pain (LBP) core sets. METHODS: The study has a cross-sectional and retrospective design and involves 20 lumbar fusion patients. Using the ICF, qualitative content analysis of semi-structured interviews 3-6 months post-surgery was performed. This was compared with the ICF related content of the Oswestry Disability Index (ODI), Medical Outcome Study Short Form 36 (SF-36), European Quality of Life Questionnaire (EQ5D) and the ICF LBP core sets. RESULTS: Patient's experiences were most frequently linked to psychological, sensory, neuromusculoskeletal and movement related body function chapters of the ICF. The most frequently linked categories of activity and participation were mobility, domestic activities, family relationships, work, recreation and leisure. Environmental factors frequently linked were the use of analgesics, walking aids, family support, social security systems, health care systems and labour market employment services. CONCLUSIONS: This study highlights important ICF related aspects of patient's experiences post-lumber fusion. The use of the comprehensive ICF core sets is recommended in conjunction with ODI, SF-36 and the EQ5D for a broader analysis of patient outcomes post-lumbar fusion.

The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients.

OBJECTIVES: To assess the extent to which perceived pain and psychological factors explain levels of disability and health-related quality of life (HRQOL) in patients scheduled for lumbar fusion surgery, and to test the hypothesis that relationships between pain intensity, mental health, fear of movement/(re)injury, disability and HRQOL are mediated by cognitive beliefs and appraisals. DESIGN: Cross-sectional, correlation study. SETTING: Orthopaedic outpatient setting in a tertiary hospital. PARTICIPANTS: One hundred and seven chronic back pain patients scheduled for lumbar fusion surgery. MEASURES: Visual analogue scale for pain intensity, Short Form 36 mental health subscale, Tampa Scale for Kinesiophobia, Back Beliefs Questionnaire, Self-efficacy Scale, Coping Strategy Questionnaire, Oswestry Disability Index and European Quality of Life Questionnaire. RESULTS: The group effect of multiple mediators significantly influenced the relationships between pain intensity and mental health, fear of movement/(re)injury, functional disability and HRQOL. Pain catastrophising significantly mediated the relationship between pain intensity and mental health, control over pain significantly mediated the relationship between mental health and functional disability, self-efficacy and pain outcome expectancy significantly mediated the relationship between mental health and HRQOL, and self-efficacy also significantly mediated the relationship between pain intensity, fear of movement/(re)jury and functional disability. The model explained 28, 30, 52 and 42% of the variation in mental health, fear of movement/(re)injury, functional disability and HRQOL, respectively. CONCLUSIONS: This study highlights the strong influence and mediation roles of psychological factors on pain, mental health, fear of movement/(re)injury, disability and HRQOL in patients scheduled for lumber fusion. Future research should focus on screening as well as pre- and post-operative interventions based on these psychological factors for the potential improvement of lumber fusion surgery outcomes.

Early rehabilitation targeting cognition, behavior, and motor function after lumbar fusion: a randomized controlled trial.

STUDY DESIGN: Open label randomized controlled trial with 3-, 6-, 12-month, and 2- to 3-year follow-up. OBJECTIVE: To investigate the effectiveness of a psychomotor therapy focusing on cognition, behavior, and motor relearning compared with exercise therapy applied during the first 3 months after lumbar fusion. SUMMARY OF BACKGROUND DATA: Postoperative management after lumbar fusion commonly focuses on analgesic pain control and activities of daily living. After 3 months, exercise therapy is often implemented. No randomized controlled trial has investigated early rehabilitation techniques conducted during the first 3 months after surgery. METHODS: The study recruited 107 patients, aged 18 to 65 years, selected for lumbar fusion because of 12 months of symptomatic spinal stenosis, spondylosis, degenerative/isthmic spondylolisthesis, or degenerative disc disease. The exercise therapy group received a home program focusing on pain contingent training of back, abdominal, and leg muscle functional strength and endurance, stretching, and cardiovascular fitness. The psychomotor therapy group received a home program and 3 outpatient sessions focusing on modifying maladaptive pain cognitions, behaviors, and motor control.Rated questionnaires investigating functional disability, pain, health-related quality of life, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, and coping were assessed at 3, 6, 12 months, and 2 to 3 years after surgery. RESULTS: Follow-up rates were 93% at 12 months and 81% at 2 to 3 years after surgery. Psychomotor therapy improved functional disability, self-efficacy, outcome expectancy, and fear of movement/(re)injury significantly more than exercise therapy at respective follow-up occasions. Similar results occurred for pain coping but group differences were nonsignificant at 2 to 3 years follow-up. Potentially clinical relevant higher reoperation rates occurred after psychomotor therapy but rates were within normal ranges. CONCLUSION: The study shows that postoperative rehabilitation can be safely implemented during the first 3 months after lumbar fusion and should include measures to modify psychological as well as motor functions.

Qualitative analysis of the male experience of heart failure.

OBJECTIVE: The purpose of this study was to gain insight from the patient's perspective into how it is to live with moderate chronic heart failure (HF). METHODS: Twenty men with moderate chronic HF in New York Heart Association classes II to III, aged 43 to 73 years, were interviewed with open-ended questions. The interviews were analyzed using qualitative inductive content analysis as a method. RESULTS: Both the consequences of the illness and how the patients adjusted to them were described in the narratives. The consequences were physical, emotional, cognitive, social, and vocational and included thoughts about death. Adjusting to the illness involved changing one's lifestyle, being aware of one's physical ability and disability, developing psychologic strategies, and adjusting to medication. CONCLUSIONS: The findings of this study demonstrate a wider range of disabilities as a consequence of moderate chronic HF and show several more ways of adjusting to the illness than previously reported in men.

Beneficial therapeutic effects of physical training and relaxation therapy in women with coronary syndrome X.

BACKGROUND AND PURPOSE: New types of illness are being identified continuously. Owing to the demands for evidence-based practice, physiotherapeutic interventions need to be investigated scientifically prior to application in a new patient population. Coronary syndrome X (syndrome X) is a chronic pain disorder with exercise-induced chest pain despite angiographically normal coronary arteries. Patients with syndrome X constitute a therapeutic problem with considerable residual morbidity associated with functional limitation and reduced quality of life. Therefore, the aim of the present study was to investigate the effects of physical training and relaxation therapy on exercise capacity and quality of life in patients with syndrome X. METHOD: A single-blind, randomized controlled trial design was used. Twenty-four female patients aged 41-65 years were randomly assigned to three groups: A, B and C. All groups were similar at baseline for physical fitness level. Group A performed physical training for eight weeks at 50% of baseline VO2max and group B participated in relaxation therapy for eight weeks. Group C acted as control subjects without any intervention. Before and after the eight-week periods, subjects were assessed by means of several measures of exercise capacity and quality of life. RESULTS: The measured variables did not change in the control group during the eight weeks. VO2max (< 0.02), work rate (< 0.002) and distance walked during six minutes (< 0.003) increased only after physical training. The tolerated exertion during six minutes of walking (< 0.05) and the health-related quality of life, measured both by the Stress and Crisis Inventory (SCI) and the Sickness Impact Profile (SIP) (< 0.04), improved after both physical training and relaxation therapy. The general coping capacity, measured by the Sense of Coherence (SOC) questionnaire, remained unchanged in all the groups. CONCLUSIONS: Female patients with syndrome X benefit from physical training in terms of exercise capacity and quality of life and from relaxation therapy in terms of quality of life.