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).

Brain mediators of negative affect-induced physical symptom reporting in patients with functional somatic syndromes.

Functional somatic syndromes (FSS) include fibromyalgia, irritable bowel syndrome (IBS), and others. In FSS patients, merely viewing negative affective pictures can elicit increased physical symptoms. Our aim was to investigate the neural mechanisms underlying such negative affect-induced physical symptoms in FSS patients. Thirty patients with fibromyalgia and/or IBS and 30 healthy controls (all women) watched neutral, positive and negative affective picture blocks during functional MRI scanning and rated negative affect and physical symptoms after every block. We compared brain-wide activation during negative versus neutral picture viewing in FSS patients versus controls using robust general linear model analysis. Further, we compared neurologic pain signature (NPS), stimulus intensity-independent pain signature (SIIPS) and picture-induced negative emotion signature (PINES) responses to the negative versus neutral affect contrast and investigated whether they mediated between-group differences in affective picture-induced physical symptom reporting. More physical symptoms were reported after viewing negative compared to neutral pictures, and this effect was larger in patients than controls (p = 0.025). Accordingly, patients showed stronger activation in somatosensory regions during negative versus neutral picture viewing. NPS, but not SIIPS nor PINES, responses were higher in patients than controls during negative versus neutral pictures (p = 0.026). These differential NPS responses partially mediated between-group differences in physical symptoms. In conclusion, picture-induced negative affect elicits physical symptoms in FSS patients as a result of activation of somatosensory and nociceptive brain patterns, supporting the idea that affect-driven alterations in processing of somatic signals is a critical mechanism underlying FSS.

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.

Factors Associated With the Ultrasound Characteristics of the Lumbar Multifidus: A Systematic Review.

OBJECTIVE: The first aim of this review was to investigate the association between age, sex, height, weight, physical activity level, posture, lumbar level and body side, and structural characteristics (cross-sectional area [CSA], thickness, linear dimensions, and echo intensity) of the lumbar multifidus (LM) measured by ultrasound. Second, differences between healthy individuals and patients with chronic low back pain (CLBP) were investigated. TYPE: Systematic review. LITERATURE SURVEY: PubMed, Embase and Web of Science were searched until September 2018. METHODOLOGY: Studies were included if (a) full text was available in English, Dutch, or French; (b) participants were older than 18 years of age and were asymptomatic or had nonspecific CLBP; and (c) the relation between structural characteristics of the LM, measured by ultrasound, and at least one of the above-mentioned factors was described, and/or a comparison between a CLBP and control group was made. Data were extracted independently by two reviewers. Quality of studies was assessed using an adapted version of the Downs and Black checklist. SYNTHESIS: Twenty-seven studies were included. Thickness and CSA of the LM do not correlate with age. Males have a larger LM size than females. Thickness and CSA of left and right LM are highly correlated in healthy subjects. More significant side-to-side differences are present in subjects with CLBP than in those without. Muscle size increases from proximal to caudal lumbar levels. The presence of CLBP is associated with muscle size and function. CONCLUSIONS: The association between the factors age, sex, height, weight, physical activity level, posture, lumbar level, body side, and presence of CLBP, and the ultrasound characteristics of the LM is discussed. These factors should be taken into account in future research on structural muscle characteristics, or when correlating with functional behavior or investigating the effect of a targeted intervention. LEVEL OF EVIDENCE: I.

The Belgian national guideline on low back pain and radicular pain: key roles for rehabilitation, assessment of rehabilitation potential and the PRM specialist.

Low back pain (LBP) and radicular pain are very common health problems. They are rarely caused by serious underlying pathology and will usually recover spontaneously in time. In about one third of the cases however, the pain and functional impairment will persist one year after onset, being responsible for high health care costs and work absence. The management of LBP and radicular pain should focus therefore on excluding signs and symptoms of serious underlying pathology, on an active approach and on the prevention of chronicity. In 2017 the Belgian Health Care Knowledge Centre (KCE) published a guideline on LBP and radicular pain. This guideline formed the basis for a national pathway on LBP and radicular pain and is the first step to change and optimize our daily clinical practice. In this Belgian guideline the importance is stressed of a comprehensive clinical assessment and a tailored rehabilitation. Pharmacological and invasive treatments have a more doubtful effect or should only be considered under certain conditions. Implementing these recommendations in an interdisciplinary pathway necessitates a central role for Physical and Rehabilitation Medicine (PRM) especially in giving advice on and/or coordinating the tailored rehabilitation to prevent chronicity. To do this, the PRM specialist should perform a medical and functional assessment according to the ICF framework and taking into account the risk for chronicity or persistent impairment and the rehabilitation potential.

The pivotal role for the multidisciplinary approach at all phases and at all levels in the national pathway for the management of low back pain and radicular pain in Belgium.

INTRODUCTION: High level evidence on management of spinal disorders is scarce, which results in guidelines being of limited practical use for practitioners. Care pathways are complex interventions intended for the mutual decision making of organization of care processes for a well-defined group of patients. The goal of this project was to design a pathway for the management of low back pain and radicular pain for national implementation in Belgium. EVIDENCE ACQUISITION: An international and Belgian study on characteristics of low back pain care pathways was performed along with a literature study and focus group interrogation. Based on essential building elements identified and a consensus approach among all relevant stakeholders in primary, hospital and reintegration care, a national pathway was constructed. The process was endorsed by the Belgian Health Care Knowledge Center, Belgian National Institute of Health and Disability Insurance and the Spine Society of Belgium. EVIDENCE SYNTHESIS: Eleven international pathways were identified, varying in implementation width from hospital-based to region/province-based. Seven Belgian pathway initiatives were detected. Notwithstanding differences, consistent building elements were identified. Three groups of caregivers, divided in primary care, hospital care and reintegration and including all relevant medical/paramedical disciplines, worked on integrating the essential building elements into a single concrete patient pathway of direct use to any caregiver and patient and based on a consensus model including reference to the 2017 Belgian adaptation of the 2016 NICE guidelines. The resulting pathways on management of low back pain and radicular pain underpin the importance of multidisciplinary teamwork. CONCLUSIONS: Essential building elements were identified from literature and established pathways and were successfully integrated in a Belgian national low back pain and radicular pain pathway using an integrative consensus approach. The pathways are consultable at www.lowbackpain.kce.be.

Postoperative bracing after lumbar surgery: a survey amongst spinal surgeons in Belgium.

PURPOSE: Bracing is frequently prescribed following lumbar surgery for degenerative conditions. However, previous studies failed to demonstrate the advantage of postoperative lumbar bracing in both short- and long-term outcome in terms of pain, quality of life and fusion rate. The purpose of this study was to assess the prescription patterns and rationale for postoperative bracing amongst spinal surgeons in Belgium. METHODS: A 16-item online survey was distributed by email to spinal surgeons affiliated to the Spine Society of Belgium (N = 252). RESULTS: A total of 105 surgeons (42%) completed the survey. The overall bracing frequency following lumbar surgery was 38%. A brace was more often prescribed following the fusion procedures (52%) than after the non-fusion procedures (21%) (p < 0.0001). The majority of surgeons (59%) considered bracing after at least one type of lumbar surgery. Orthopaedic surgeons (73%) reported a significantly higher rate of prescribing postoperative bracing compared to neurosurgeons (44%) (p = 0.003). Pain alleviation (67%) was the main goal for prescribing a postoperative brace. A total of 42% of the surgeons aimed to improve fusion rate by bracing after lumbar fusion procedures. A quasi-equal level of the scientific literature (29%), personal experience (35%) and teaching from peers (36%) was reported to contribute on the attitudes towards prescribing bracing. CONCLUSIONS: Postoperative bracing was prescribed by Belgian spinal surgeons following more than one-third of lumbar procedures. This was underpinned by beliefs regarding pain alleviation and higher fusion rate. Interestingly, based on the scientific literature these beliefs have been demonstrated to be false. These slides can be retrieved under Electronic Supplementary Material.

Cortisol and Subjective Stress Responses to Acute Psychosocial Stress in Fibromyalgia Patients and Control Participants.

OBJECTIVE: Hypothalamic-pituitary-adrenal axis dysfunction may play a role in fibromyalgia (FM) pathogenesis but it remains understudied in this disorder. Furthermore, early childhood adversities (ECA) are common in FM, but whether they moderate stress reactivity is unknown. Hence, we investigated cortisol and subjective responses to acute psychosocial stress in FM and controls, while adjusting for ECA. METHODS: Twenty-seven female FM patients and 24 age-matched female controls were recruited in a tertiary care center and through advertisements, respectively. The Childhood Trauma Questionnaire was used to measure ECA history. Salivary cortisol levels and subjective stress ratings were measured at multiple time points before and after the Trier Social Stress Test (TSST) was administered. RESULTS: Significant main effects of group [F(1,43) = 7.04, p = .011, lower in FM] and ECA [F(1,43) = 5.18, p = .028, higher in participants with ECA] were found for cortisol responses. When excluding controls with ECA (n = 5), a significant group-by-time interaction was found [F(6,39) = 2.60, p = .032], driven by a blunted response to the stressor in FM compared with controls (p = .037). For subjective stress responses, a significant main effect of group [F(1,45) = 10.69, p = .002, higher in FM] and a trend toward a group-by-time interaction effect [F(6,45) = 2.05, p = .078, higher in FM 30 minutes before and 30 and 75 minutes after the TSST, and impaired recovery (difference immediately after - 30 minutes after the TSST) in FM] were found. CONCLUSIONS: Blunted cortisol responsivity to the TSST was observed in FM patients compared with controls without ECA. FM patients had higher subjective stress levels compared with controls, particularly at baseline and during recovery from the TSST. In FM patients, ECA history was not associated with cortisol or subjective stress levels or with responsivity to the TSST. Future research should investigate the mechanisms underlying hypothalamic-pituitary-adrenal axis dysregulation in FM.

The presence of respiratory disorders in individuals with low back pain: A systematic review.

BACKGROUND: Inspiratory muscles, such as the diaphragm, play a key role in both respiration and spinal control. Therefore, diaphragm dysfunctions are often related to low back pain (LBP). However, few is known on the association between the presence of LBP and the presence of respiratory disorders (RD). OBJECTIVES: To perform a systematic review on the relation between RD and LBP. STUDY DESIGN: Systematic review. METHODS: Two reviewers searched on PubMed/MEDLINE for studies concerning LBP and RD, from 1950 up to January 2016. The search string consisted of the following key words: low back pain, dyspnea, respiratory problems, lung diseases, comorbidity, pulmonary disease, chronic obstructive, smoking, asthma, allergy, sinusitis, respiratory tract infection and hyperventilation. The aim was to evaluate a potential correlation, co-occurrence or causality between RD and LBP. RESULTS: A total of 16 articles were included. A significant correlation between the presence of LBP and the presence of RD such as dyspnea, asthma, different forms of allergy, and respiratory infections was found. No correlation was found between Chronic Obstructive Pulmonary Disease (COPD) and LBP, and no articles were found on the correlation between hyperventilation and LBP. CONCLUSIONS: This is the first study providing an overview of the literature on the relation between LBP and RD. Immunological, biomechanical, psychosocial and socio-economic factors might explain this correlation. Smoking is likely to contribute. Future studies must reveal the causative relationship. LEVEL OF EVIDENCE: Therapy, level 2a.

Typology of patients with fibromyalgia: cluster analysis of duloxetine study patients.

BACKGROUND: To identify distinct groups of patients with fibromyalgia (FM) with respect to multiple outcome measures. METHODS: Data from 631 duloxetine-treated women in 4 randomized, placebo-controlled trials were included in a cluster analysis based on outcomes after up to 12 weeks of treatment. Corresponding classification rules were constructed using a classification tree method. Probabilities for transitioning from baseline to Week 12 category were estimated for placebo and duloxetine patients (Ntotal = 1188) using logistic regression. RESULTS: Five clusters were identified, from "worst" (high pain levels and severe mental/physical impairment) to "best" (low pain levels and nearly normal mental/physical function). For patients with moderate overall severity, mental and physical symptoms were less correlated, resulting in 2 distinct clusters based on these 2 symptom domains. Three key variables with threshold values were identified for classification of patients: Brief Pain Inventory (BPI) pain interference overall scores of <3.29 and <7.14, respectively, a Fibromyalgia Impact Questionnaire (FIQ) interference with work score of <2, and an FIQ depression score of ≥5. Patient characteristics and frequencies per baseline category were similar between treatments; >80% of patients were in the 3 worst categories. Duloxetine patients were significantly more likely to improve after 12 weeks than placebo patients. A sustained effect was seen with continued duloxetine treatment. CONCLUSIONS: FM patients are heterogeneous and can be classified into distinct subgroups by simple descriptive rules derived from only 3 variables, which may guide individual patient management. Duloxetine showed higher improvement rates than placebo and had a sustained effect beyond 12 weeks.

Self-critical perfectionism predicts outcome in multidisciplinary treatment for chronic pain.

BACKGROUND: Self-critical perfectionistic personality features have been shown to influence the onset and perpetuation of pain symptoms. However, no study to date has investigated whether these personality features are associated with treatment response in chronic pain. METHODS: Using a naturalistic pre-post design, the present study examined the effect of self-critical perfectionism on treatment outcome in terms of self-reported pain. The study was conducted in a sample of 53 chronic non-cancer pain patients who followed Multidisciplinary Pain Education Program (MPEP), a brief, 2-week cognitive-behaviorally based psycho-educational intervention for chronic pain that was recently found to be effective in reducing pain severity. Pre- and post-treatment pain intensity levels were assessed with the visual analog scale of the McGill Pain Questionnaire-Short Form. RESULTS: Pretreatment self-critical perfectionism was significantly associated with negative treatment outcome, even after taking into account pretreatment levels of depression. CONCLUSION: Results suggest that self-critical perfectionistic personality features may negatively interfere with treatment response in patients with chronic pain. Thus, findings indicate that chronic pain patients with high levels of self-critical perfectionism may benefit less from brief interventions such as MPEP, and therefore may need more intensive and tailored treatment.

The prevalence and impact of early childhood trauma in Chronic Fatigue Syndrome.

BACKGROUND: Although some studies have found high rates of early childhood trauma in Chronic Fatigue Syndrome (CFS), the role of early trauma in this condition remains controversial. METHODS: This study examined the prevalence of early childhood trauma and its impact on daily fatigue and pain levels over a 14-day period in a sample of 90 carefully screened CFS patients using a diary method approach. Data were analyzed using multilevel analysis. RESULTS: More than half of the patients (54.4%) had experienced at least one type of early trauma, with the majority of these patients reporting multiple traumas. Prevalence rates were particularly high for emotional trauma (i.e., emotional abuse and/or emotional neglect) (46.7%). Moreover, total trauma scores and emotional abuse significantly predicted higher levels of daily fatigue and pain over the 14-day period, even when controlling for demographic features and depressed mood. CONCLUSIONS: This is the first study to demonstrate that early childhood trauma predicts increasing levels of core symptoms of CFS in the daily flow of life. Moreover, findings of this study suggest that emotional trauma may be particularly important in CFS.

Prevalence of DSM-IV personality disorders in patients with chronic fatigue syndrome: a controlled study.

BACKGROUND: It is not yet clear whether chronic fatigue syndrome (CFS) is associated with elevated levels of personality disorders. PURPOSE: This study aims to determine the prevalence of DSM-IV axis II personality disorders among patients with CFS. METHODS: We examined the prevalence of personality disorders in a sample of 92 female CFS patients and in two well-matched control groups, i.e., normal community individuals (N = 92) and psychiatric patients (N = 92). Participants completed the assessment of DSM-IV personality disorders questionnaire (ADP-IV), which yields a categorical and dimensional evaluation of personality disorder features. RESULTS: The prevalence of personality disorders in CFS patients (16.3 %) was significantly lower than in psychiatric patients (58.7 %) and was similar to that in the community sample (16.3 %). Similar results were found for dimensional and pseudodimensional scores, except for the Depressive (DE) and Obsessive-Compulsive Personality Disorder (O-C) subscales. Patients with CFS had significantly higher levels of DE features compared to normal controls and similar dimensional scores on the O-C scale compared to psychiatric controls. CONCLUSIONS: Although the CFS sample was characterized by depressive and obsessive-compulsive personality features, this study provides no evidence for the assumption that these patients generally show a higher prevalence of axis II pathology. Given the conflicting findings in this area, future studies using multiple measures to assess personality disorders in CFS are needed to substantiate these findings.