Preoperative Neuroscience Education for Lumbar Radiculopathy · APTA CSM Anaheim . February 17-20,...
Transcript of Preoperative Neuroscience Education for Lumbar Radiculopathy · APTA CSM Anaheim . February 17-20,...
APTA CSM Anaheim February 17-20, 2016
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Preoperative Neuroscience
Education for Lumbar
Radiculopathy Adriaan Louw, PT, PhD
Louie Puentedura, PT, PhD, DPT, OCS, FAAOMPT
Combined Sections Meeting 2016
Anaheim, California, February 17 -20, 2016
Disclaimers…
We publish books on pain and receive an honorarium for the sales. These are not being specifically promoted in the
presentation. The intent is to share our research and not promote products.
We teach for a seminar company offering continuing education for
healthcare providers. The session is not designed to promote the attendance of
the seminars.
Learning Objectives
Upon completion of this educational session the participants will be able to:
• Understand why a new bio-psycho-social approach was needed to address pain in lumbar surgery
• Understand the development and validation process of the preoperative neuroscience education program for lumbar surgery
• Be able to understand the content and delivery methods for the preoperative neuroscience educational program
• Recognize why the preoperative neuroscience educational program produced superior results to the biomedical model utilized by US spine surgeons for lumbar surgery
• Apply the information from the educational session into clinical practice
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What is the biggest predictor of you
having Back Surgery in the US?
Age
Pain
Insurance
Zip Code
Ratio of Rates of CT/MRI
scanning to the US Average
Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine. Mar 15
2003;28(6):616-620.
Ratio of rates for spine
surgery in the US average
Spinal Surgery in the US
• The likelihood of having spinal surgery in the US is 5 times higher than that of the United Kingdom, and at least twice than the surgery rates of Australia, Canada and Scandinavian countries.
Cherkin DC, Deyo RA, Loeser JD,
Bush T, Waddell G. An international
comparison of back surgery rates.
Spine. Jun 1 1994;19(11):1201-
1206.
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We’re Number One!
Increased Lumbar Fusions
• Between 1996 – 2001 – Spinal fusions rose by 77%
– Total hip arthroplasty (THA) and total knee arthroplasty (TKA) rose by 13%
Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res. Feb 2006;443:139-146.
• Patients with DDD: – Between 1990 – 1993: 9.4% underwent
spinal fusion
– Between 1997 – 2000: 19.1% underwent spinal fusion (> 200% increase)
• In addition to a rising rate of lumbar fusion surgery, it seems an increasing proportion of all spine operations include a fusion procedure: – For spinal stenosis, spine fusions
quadrupled
Fusions with cages increased from 3.6% in 1996 to 58.1% in 2001. (1500% increase)
Outpatient Ambulatory Surgery
• Discectomies performed on
outpatients rose from 4% in 1994
to 26% in 2000
• 650% increase
Gray DT, Deyo RA, Kreuter W, et al. Population-
based trends in volumes and rates of ambulatory
lumbar spine surgery. Spine. Aug 1
2006;31(17):1957-1963; discussion 1964.
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Spinal Stenosis: 2002 - 2007
• Rate of complex fusion procedures increased 15-fold
• Life-threatening complications increased
• Re-hospitalization within 30 days • 7.8% of patients undergoing
decompression
• 13.0% having a complex fusion
– Mean hospital charges for complex fusion: $80,888
Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with
surgery for lumbar spinal stenosis in older adults. JAMA : the journal of the American Medical Association. Apr 7 2010;303(13):1259-1265.
• Recent analyses of research in orthopedic and spine surgery have demonstrated significantly more favorable results in corporate-sponsored studies.
• The surgeons themselves are guilty of being insufficiently critical of products and techniques they are developing. More people are interested in getting “on the gravy train than on stopping the gravy train”
- Dr. Richard Deyo, MD
Diagnosis & Indication for Surgery? • Several authors indicate that surgery rates may be linked to a poor
consensus of indication for specific surgical procedures and even the increased rates of surgery for geriatric patients.
Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain: injections and surgical interventions: results of the Bone
and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. Feb 15 2008;33(4
Suppl):S153-169.
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So What if
Surgery Is
Increasing?
Patients only care about…
Loss of Pain
Improved Function
No complications
1. Louw, A., Q. Louw, et al. (2009). "Preoperative Education for Lumbar Surgery for Radiculopathy." South African
Journal of Physiotherapy 65(2): 3-8.
2. Lurie, J. D., S. H. Berven, et al. (2008). "Patient preferences and expectations for care: determinants in patients with
lumbar intervertebral disc herniation." Spine 33(24): 2663-2668.
3. Toyone, T., T. Tanaka, et al. (2005). "Patients' expectations and satisfaction in lumbar spine surgery." Spine 30(23):
2689-2694.
4. Yee, A., N. Adjei, et al. (2008). "Do patient expectations of spinal surgery relate to functional outcome?" Clin Orthop
Relat Res 466(5): 1154-1161.
Laminectomy/Laminotomy
• Success rate ~ 80%
• Effective for leg symptoms – pain, neurological, etc.
• Most research – spinal stenosis
• Long-term slightly better than conservative care
• Indicated in neurological deficit
1. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of lumbar
spinal stenosis: 8 to 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). Apr 15 2005;30(8):936-943.
2. Pao, J. L., W. C. Chen, et al. (2009). "Clinical outcomes of microendoscopic decompressive laminotomy for degenerative
lumbar spinal stenosis." Eur Spine J 18(5): 672-678.
3. Weinstein, J. N., T. D. Tosteson, et al. (2010). "Surgical versus nonoperative treatment for lumbar spinal stenosis four-year
results of the Spine Patient Outcomes Research Trial." Spine (Phila Pa 1976) 35(14): 1329-1338.
4. Fu, Y. S., B. F. Zeng, et al. (2008). "Long-term outcomes of two different decompressive techniques for lumbar spinal stenosis."
Spine (Phila Pa 1976) 33(5): 514-518.
5. Oertel MF, Ryang YM, Korinth MC, Gilsbach JM, Rohde V. Long-term results of microsurgical treatment of lumbar spinal
stenosis by unilateral laminotomy for bilateral decompression. Neurosurgery. Dec 2006;59(6):1264-1269; discussion 1269-
1270.
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Discectomy – very well studied
• The reported success rate of
lumbar disc surgery varies from
60% to 90% (Ave 80%)
1. Korres DS, Loupassis G, Stamos K. Results of lumbar discectomy: a study using 15 different evaluation methods.
European Spine Journal 1992;1:20–4
2. Findlay GF, Hall BI, Musa BS, Oliveria MD, Fear SC. A 10-year follow-up of the outcome of lumbar microdiscectomy.
Spine 1998; 23:1168–71
3. Loupasis GA, Stamos K, Katonis PG, Sapkas G, Korres DS,Hartofilakidis G. Seven- to 20-year outcome of lumbar
discectomy. Spine 1999;24:2313–7.
4. Yorimitsu E, Chiba K, Toyama Y, et al.Long term outcomes of standard discectomy for Lumbar Disc Herniation. Spine
2001;26:652– 8.
Microdiscectomy
• Have not yet shown any advantage over traditional discectomy – Porchet F, Bartanusz V, Kleinstueck FS, et al. Microdiscectomy
compared with standard discectomy: an old problem revisited with new outcome measures within the framework of a spine surgical registry. Eur Spine J. Aug 2009;18 Suppl 3:360-366.
– Veresciagina K, Spakauskas B, Ambrozaitis KV. Clinical outcomes of patients with lumbar disc herniation, selected for one-level open-discectomy and microdiscectomy. Eur Spine J. Sep 2010;19(9):1450-1458.
– Teli M, Lovi A, Brayda-Bruno M, et al. Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy. Eur Spine J. Mar 2010;19(3):443-450.
• Microdiscectomy gives broadly comparable results to open discectomy. – Gibson JN, Waddell G. Surgical interventions for lumbar disc
prolapse. Cochrane Database Syst Rev. 2007(2):CD001350.
Discectomy – Summary
• 80% success rate
• Predominantly for leg
pain due to HNP
• No difference between
open vs.
microdiscectomy
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Fusions
• No conclusions are possible
about the relative
effectiveness of anterior,
posterior, or circumferential
fusion.
Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine.
Oct 15 2005;30(20):2312-2320.
Fusion – Summary
• At best – coin toss: 50% success rate
• Significant complications – Double risks compare to
decompression surgery
– Blood transfusion x 6
– Double postoperative mortality
1. Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spinal fusion. A cohort study of complications, reoperations, and
resource use in the Medicare population. Spine. Sep 1 1993;18(11):1463-1470.
2. Button G, Gupta M, Barrett C, Cammack P, Benson D. Three- to six-year follow-up of stand-alone BAK cages implanted by a
single surgeon. Spine J. Mar-Apr 2005;5(2):155-160.
3. Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicenter Food and Drug Administration investigational
device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I:
evaluation of clinical outcomes. Spine. Jul 15 2005;30(14):1565-1575; discussion E1387-1591.
4. Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in
patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. May
2006;122(1-2):145-155.
5. Fenton JJ, Mirza SK, Lahad A, Stern BD, Deyo RA. Variation in reported safety of lumbar interbody fusion: influence of industrial
sponsorship and other study characteristics. Spine. Feb 15 2007;32(4):471-480.
They may be getting the message
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Total Disc Arthroplasty
• 57% of the patients with disc
replacement met all 4 criteria for
success
• 64% still using narcotic
medications at the 2-year
follow-up
Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicenter Food and Drug Administration
investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar
fusion: part I: evaluation of clinical outcomes. Spine. Jul 15 2005;30(14):1565-1575; discussion E1387-1591.
Lumbar Disc Replacement
• 2 RCTs, 2 previous systematic reviews, 7 prospective cohort studies, 11 retrospective cohort studies and 8 case series
• To date, no study has shown total disc replacement to be superior to spinal fusion in terms of clinical outcome
• Long-term benefits of total disc replacement in preventing adjacent level disc degeneration have yet to be realized
Freeman BJ, Davenport J. Total disc replacement in the lumbar spine: a systematic review of the literature. Eur Spine J 15
Suppl 3: S439-47, 2006.
Disc Replacement Summary
• Results not as impressive as expected
• Lot’s of “hype”
• Better than fusion (coin toss at best)
• At least 30-40% of patients experience
persistent pain and disability
1. Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicenter Food and Drug Administration investigational
device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of
clinical outcomes. Spine. Jul 15 2005;30(14):1565-1575; discussion E1387-1591.
2. Berg S, Tullberg T, Branth B, Olerud C, Tropp H. Total disc replacement compared to lumbar fusion: a randomised controlled trial with
2-year follow-up. Eur Spine J. Oct 2009;18(10):1512-1519.
3. Punt IM, Visser VM, van Rhijn LW, Kurtz SM, Antonis J, Schurink GW, van Ooij A. Complications and reoperations of the SB Charite
lumbar disc prosthesis: experience in 75 patients. Eur Spine J 17 (1): 36-43, 2008.
4. David T. Long-term results of one-level lumbar arthroplasty: minimum 10-year follow-up of the CHARITE artificial disc in 106 patients.
Spine 32 (6): 661-6, 2007.
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Kypho/Vertebroplasty
• Summary
– No significant evidence over conservative care or
placebo
– High incidence of fractures above/below
– Cemented vertebrae fractures also occur
AND – various medical concerns: unknowns of cement
leakage, intravascular leakage, embolisms, bleeding, etc.
US Insurance likely won’t cover the procedure
1. Schmelzer-Schmied N, Cartens C, Meeder PJ, Dafonseca K. Comparison of kyphoplasty with use of a calcium phosphate
cement and non-operative therapy in patients with traumatic non-osteoporotic vertebral fractures. Eur Spine J. May
2009;18(5):624-629.
2. Lin WC, Lee YC, Lee CH, et al. Refractures in cemented vertebrae after percutaneous vertebroplasty: a retrospective analysis.
Eur Spine J. Apr 2008;17(4):592-599.
3. Fribourg D, Tang C, Sra P, Delamarter R, Bae H. Incidence of subsequent vertebral fracture after kyphoplasty. Spine. Oct 15
2004;29(20):2270-2276; discussion 2277.
4. Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies.
Spine (Phila Pa 1976). Aug 1 2006;31(17):1983-2001.
5. Taylor RS, Fritzell P, Taylor RJ. Balloon kyphoplasty in the management of vertebral compression fractures: an updated
systematic review and meta-analysis. Eur Spine J. Aug 2007;16(8):1085-1100.
Summary
It can easily be stated that at least 1/3
(more likely 40%) of lumbar surgery
patients continue to have significant
persistent pain, disability and functional
loss.
So – a Second Surgery will fix it…right? • Deyo RA, Mirza SK. The case for restraint in spinal surgery: does quality management
have a role to play? Eur Spine J. Aug 2009;18 Suppl 3:331-337.
• Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates
following lumbar spine surgery and the influence of spinal fusion procedures. Spine. Feb
1 2007;32(3):382-387.
• Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates
following lumbar spine surgery and the influence of spinal fusion procedures. Spine. Feb
1 2007;32(3):382-387.
• Papadopoulos EC, Girardi FP, Sandhu HS, et al. Outcome of revision discectomies
following recurrent lumbar disc herniation. Spine. Jun 1 2006;31(13):1473-1476.
• Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with
cognitive intervention and exercises in patients with chronic back pain after previous
surgery for disc herniation: a prospective randomized controlled study. Pain. May
2006;122(1-2):145-155.
• He, S. C., G. J. Teng, et al. (2008). "Repeat vertebroplasty for unrelieved pain at
previously treated vertebral levels with osteoporotic vertebral compression fractures."
Spine (Phila Pa 1976) 33(6): 640-647.
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So: No-One Should Have Back Surgery?
• There are VERY DEFINITE indications: – Progressive neurological deficit
– Fractures
– Cord Compression
• Pain?
• Instability?
• Arthritis?
• The bad news: 1. Ostelo et al 2003a: 6-month results of behavioral
graded activities versus usual care, showed no difference in regards to functional status, pain, pain catastrophisation, fear of movement, ROM, general health, social functioning or return to work.
2. Ostelo et al 2003b: One year follow-up: No difference
3. Donaldson et al 2006: Intensive 6-month rehab program in 3 phases vs. “continue normal ADL’s” – no difference
4. Cochrane Review: One year follow-up of PT vs. no treatment show no advantage for rehab.
5. Christensen et al 2003: No benefit of PT rehab compared to HEP, video and support group meetings.
6. Timm, KE et al: Low quality RCT show limited effect of exercise
7. Danielson 2000 – no long term benefits to exercise
8. Manniche 1993 – no long term benefits to exercise
9. Mannion et al 2007: No benefit of PT over “act as usual”
• The good news: 1. Cochrane: Intensive PT for 4-6
weeks result in better short term outcomes compared to no rehabilitation.
2. Dolan et al, 2000: PT exercise, education and ADL advice beneficial for pain, disability, ROM and muscle endurance.
3. Filiz et al 2005: Intensive exercise increase lifting from waist to shoulder, abdominal endurance, and disability as measured by the modified Oswestry Disability Index.
4. Danielson 2000: Short term benefit of exercise
5. Manniche 1993: Short term benefit of exercise
Postoperative rehab…
Rehabilitation after lumbar disc surgery
Cochrane Database Syst Rev. 2004
• Thirteen studies were included, six of which were of high
quality.
• There is no evidence that patients need to have their activities restricted
after first time lumbar disc surgery.
• There is strong evidence for intensive exercise programs (at least if
started about 4-6 weeks post-operative) on short term for functional
status and faster return to work and there is no evidence they increase
the re-operation rate.
• It is unclear what the exact content of post-surgery rehabilitation should
be.
• Moreover, there are no studies that investigated whether active
rehabilitation programs should start immediately post-surgery or
possibly four to six weeks later.
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What about preoperative interventions?
In 1975 and 1978 two pioneer
studies by Hayward and Boore
demonstrated that structured
preoperative education had an
effect on postoperative pain,
anxiety and recovery.
Preoperative Education: Orthopedics
• Positive effect • Preoperative anxiety levels
• Patient knowledge
• No changes to postoperative outcomes
• Pain
• ROM
• Function
• Length of hospital stay
Preoperative Education: Orthopedics
“Little evidence that
preoperative education provide
superior results in regards to
pain, functioning and LOH
when compared to “usual care”
in total hip and knee
replacement patients
Modest effect in decreasing
anxiety prior to surgery
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Preoperative Education: Orthopedics
• Since the review – several RCT’s
• No significant difference postoperatively
(Beaupre, Lier et al. 2004; Gocen, Sen et al. 2004; McGregor, Rylands et al. 2004; Chen and Yeh 2005;
Yeh, Chen et al. 2005; Johansson, Salantera et al. 2007; Ferrara, Rabini et al. 2008; Heikkinen, Helena et
al. 2008; Thomas and Sethares 2008; Vukomanovic, Popovic et al. 2008; Beamond, Beischer et al. 2009;
Lubbeke, Suva et al. 2009; Yoon, Nellans et al. 2009
Why is it not helping?
• Procedural information
• Informed consent
• No postoperative benefit
(Douglas, Mann et al. 1998; Krupp, Spanehl et al. 2000;
LaMontagne, Hepworth et al. 2003; Johansson, Nuutila et
al. 2005; Walters and Coad 2006
Preoperative Education Lumbar Surgery
• Louw, A., et al 2009: – Patients require more preoperative information regarding the surgical
procedure, the potential risks, and the limitations and benefits of surgery
– More information on their pain and how surgery will impact pain.
• McGregor et al 2007: – Patients require more preoperative information
• Ronnberg et al, 2007: – Patients in general satisfied with the care given to them preoperatively
– Not with the content of the information regarding the impending spinal surgery.
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So where are we at?
In the meantime…
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In the meantime…
The BRAIN should be a major FOCUS in
addressing pain and disability in
Lumbar Surgery
1. What do lumbar surgery (LS) patients want?
2. What constitutes “usual” preoperative LS
education?
3. What does the general population think
about LS?
4. Is there any effective preoperative strategy
that can be borrowed?
5. Is there any other effective strategy that can
be borrowed for complex back patients?
6. What happens when a “surgical” brain
understands more?
7. Can we develop a LS program using all of
this information?
8. Does such a LS program produce superior
results?
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1. What do lumbar surgery (LS) patients want?
New questionnaires developed
• Patient study
– Administered to patients at their first postoperative visit with the surgeon – within 4 weeks postoperatively
• Physiotherapist study
– 1000 randomized physiotherapists
– Must treat postoperative L-spine patients
– 2-years clinical experience
Louw A, Louw Q, Crous LCC. Preoperative Education for Lumbar Surgery for Radiculopathy. South African Journal of
Physiotherapy. July 2009 2009;65(2):3-8.
1. What do lumbar surgery (LS) patients want?
Is preoperative education important?
• 100% of patients – YES
• 99% of therapists – YES
• 92% of therapists rated preoperative
education more important than
postoperative education
Louw A, Louw Q, Crous LCC. Preoperative Education for Lumbar Surgery for Radiculopathy. South African Journal of
Physiotherapy. July 2009 2009;65(2):3-8.
1. What do lumbar surgery (LS) patients want?
• 76% of patients underwent surgery for pain • Although 97% of patients thought their preoperative
education was beneficial – More than 1/3 felt they did not get enough education on
pain
• 50% of patients surveyed at 4 weeks postoperative was afraid pain will get worse
Louw A, Louw Q, Crous LCC. Preoperative Education for Lumbar Surgery for Radiculopathy. South African Journal of
Physiotherapy. July 2009 2009;65(2):3-8.
Patients want to know more about (their) pain
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2. What constitutes “usual” preoperative LS
education?
Design and Setting: Online cross-sectional survey
Participants: Random sample of spine surgeons in the US
Interventions: Spinal Surgery Education Questionnaire developed
Main Outcome Measure(s):
Descriptive statistics were used to describe the current utilization, importance, content and delivery methods of preoperative education by spine surgeons in the US for patients with lumbar radiculopathy.
Results:
89/200 (45% response rate) surgeons responded
Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine Surgery. 2012;6:130-139.
2. What constitutes “usual” preoperative LS
education?
• Average time between decision and surgery = 17 days
• 85% reported education provided at last clinical consult
• Surgeon report educational session last approx. 15 min.
Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine Surgery. 2012;6:130-139.
2. What constitutes “usual” preoperative LS
education?
64.20%
35.80%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Informal Formal
Education Session Description
75.31%
12.35% 7.41% 4.94%
0.00%
20.00%
40.00%
60.00%
80.00%
Provider of the Educational Session
Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine Surgery. 2012;6:130-139.
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0% 1.23% 0% 1.23% 4.94% 4.94%
20.99% 19.75%
44.44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1 2 3 4 5 6 7 8 9 10
Score (out of 10)
Importance of preoperative education
2. What constitutes “usual” preoperative LS
education?
Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine Surgery. 2012;6:130-139.
28
37
27
43
25
0
5
10
15
20
25
30
35
40
45
50
Obliged(ethical/legal)
Answer questions Reduce anxiety "Better" outcomes Other
Why is preoperative education important?
2. What constitutes “usual” preoperative LS
education?
Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine Surgery. 2012;6:130-139.
Louw A, Butler DS, Diener I, Puentedura
EJ. Preoperative education for lumbar
radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine
Surgery. 2012;6:130-139.
2. What constitutes “usual” preoperative LS
education?
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2. What constitutes “usual” preoperative LS
education?
74.07%
11.11% 8.64%
0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%
Surgical procedure
Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine
Surgeons. International Journal of Spine Surgery. 2012;6:130-139.
Surgeons follow a stringent biomedical model
Unrealistic Expectations • Half of the patients expected to become
completely leg pain free, and more than
three fourths of the patients expected to
become unlimited in their walking ability
in both groups.
• Even if the clinical expectations were
met, some patients were still
dissatisfied.
2B. (You need to know this as well…)
Toyone T, Tanaka T, Kato D, Kaneyama R, Otsuka M. Patients' expectations and satisfaction in lumbar spine
surgery. Spine. Dec 1 2005;30(23):2689-2694.
3. What does the general population think about
LS?
Landers MR, Puentedura E, Louw A,
McCauley A, Rasmussen Z, Bungum T.
A population-based survey of lumbar
surgery beliefs in the United States.
Orthopaedic nursing / National
Association of Orthopaedic Nurses. Jul-
Aug 2014;33(4):207-216.
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3. What does the general population think about
LS?
• 262 participants
• Mean age = 46.1 ±16.9 years (range 60-88)
• 91.5% were current residents of Nevada (4.2% from
neighboring states and the remainder from various states
across the county)
• 76.3% non-Hispanic, 10.7% Hispanic, 8.8% other
Landers MR, Puentedura E, Louw A, McCauley A, Rasmussen Z, Bungum T. A population-based survey of lumbar surgery
beliefs in the United States. Orthopaedic nursing / National Association of Orthopaedic Nurses. Jul-Aug 2014;33(4):207-
216.
Landers, MR;
Puentedura, EJ;
Louw, A, et al.
2014. A
Population-
Based Survey
of Lumbar
Surgery Beliefs
in the United
States.
Orthopaedic
Nursing;
July/August
2014 - 33 (4)
3. What does the general population think about
LS?
The general population has a negative/ ambivalent view
of Lumbar Surgery and expecting a long recovery
4. Is there any effective preoperative strategy
that can be borrowed? • Systematic Review: Johansson, Nuutila et al. 2005
– 11 randomized controlled trials involving 1044 hip and knee arthroplasty patients.
– Preoperative education has a positive effect on preoperative anxiety levels and patient knowledge
– No changes to postoperative outcomes including pain, ROM, function or length of hospital stay.
• Cochrane - McDonald, Hetrick et al. 2004 – 9 studies involving 782 patients with knee or hip arthroplasty.
– Little evidence that preoperative education provide superior results in regards to pain, functioning and length of hospital stay when compared to “usual care” in total hip and knee replacement patients.
– Modest effect in decreasing anxiety prior to surgery.
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 21
4. Is there any effective preoperative strategy that
can be borrowed?
• The educational content centred on a description of preoperative preparation, hospital stay, surgical procedure, immediate and intermediate experiences and expectations following surgery, rehabilitation, encouragement and reassurance and answering common question associated with the surgical experience
• Only one study, utilizing pain education was able to reduce postoperative pain
Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative pain in total joint
arthroplasty: review of content and educational delivery methods. Physiotherapy theory and practice. Apr 2013;29(3):175-
194.
Louw A, Diener I, Butler DS,
Puentedura EJ.
Preoperative education
addressing postoperative
pain in total joint
arthroplasty: review of
content and educational
delivery methods.
Physiotherapy theory and
practice. Apr
2013;29(3):175-194.
4. Is there any effective preoperative strategy
that can be borrowed?
Preoperative Education for Orthopedics
• No changes to postoperative outcomes including pain, ROM, function or length of hospital stay.
• Only one study, utilizing pain education was able to reduce postoperative pain.
McDonald DD, Freeland M, Thomas G, Moore J. Testing a preoperative pain management intervention for elders. Res
Nurs Health. Oct 2001;24(5):402-409.
5. Is there any other effective strategy that can be
borrowed for complex back patients?
Emerging research shows that explaining to patients their pain
experience from a biological and physiological perspective of
how the nervous system/ brain’s processes pain allow
patients to move better, exercise better, think different about
pain, push further into pain, etc.
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic
musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056.
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 22
5. Is there any other effective strategy that
can be borrowed for complex back patients?
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress
in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056.
Also clarified content and educational delivery methods
Pain Neuroscience Education could potentially
help Lumbar Surgery patients
5B. Is there any other effective strategy that
can be borrowed for complex back patients?
The Efficacy of Therapeutic Neuroscience Education on Musculoskeletal Pain – An Updated Systematic Review of the Literature
– Adriaan Louw, PT, PhD
– Kory Zimney, PT, DPT
– Louie Puentedura, PT, PhD
– Ina Diener, PT, PhD
The results of this updated systematic review of TNE for MSK pain provides strong evidence for TNE improving pain ratings, pain knowledge, disability, pain catastrophization, fear-avoidance,
attitudes and behaviors regarding pain, physical movement and healthcare utilization. Submitted for publication
6. What happens when a “surgical” brain
understands more?
The Efficacy of Sham Surgery
in Orthopedics: A Systematic
Review of the Literature* Louw A, Diener I, Puentedura L and Fernandez de-Las
Penas C.
Submitted for Publication 2012 - 2015
* Rejected by all major spine and
orthopedic journals
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 23
6. What happens when a “surgical”
brain understands more? Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl
J Med. Aug 6 2009;361(6):557-568.
Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med.
Aug 6 2009;361(6):569-579.
Louw, A; Puentedura EJ, Diener I, et al 2015 –
submitted for publication
6. What happens when a “surgical” brain
understands more?
Conclusion: Although care
should be taken…sham
surgery has been shown to
be just as effective as actual
surgery in reducing pain and
disability.
7. Bringing it all together…
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Property of ISPI – not to be copied
without permission 24
Postop Patient
Experience
Surgeon current
education
Best evidence
Neuroscience
Education
Provocative
Language and
Surgery
Viewing images
prior to surgery General population’s
beliefs about
surgery
Expectations
following surgery
What works in pre-
op Ortho education
Sham
Empowering the
brain
Want more
info on pain
Focus on
anatomy Not helpful
unless pain
education
Afraid and
expect poor
outcome
Induces fear Effective in
reducing
pain and
disability
Louw A, Butler DS, Diener I, Puentedura EJ.
Development of a preoperative neuroscience
educational program for patients with lumbar
radiculopathy. American journal of physical
medicine & rehabilitation / Association of Academic
Physiatrists. May 2013;92(5):446-452.
Clinical Application • Physical therapist
• One-on-one verbal format
• Pictures, examples, metaphors and drawings as needed
• Conversational and personal approach rather than a lecture format.
• Standardized NE program: checklist
• The educational sessions averaged 30 minutes.
• Provided with a preoperative NE booklet; asked to read the NE booklet at least one time before and one time after their surgery.
Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a
multicenter randomized controlled trial with 1-year follow-up. Spine. Aug 15 2014;39(18):1449-1457.
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 25
1. The decision to have LS
2. The nervous system’s physiology and
pathways
Normal electrical activity
Electrical activity “waking up”
Take care of the issue
Nerves calm down
3. Peripheral nerve sensitization
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 26
4. Surgical experiences and environmental
issues effects on nerve sensitivity
5. Calming the nervous system
6. Recovery after LS
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Property of ISPI – not to be copied
without permission 27
Which story works best?
1. Overall concept that pain after surgery is normal
2. Extra sensitive alarm system
3. The body’s living alarm system
4. How to calm extra sensitive nerves
5. Surgical experience ramping nerves up
Louw, A 2015 – in preparation
Does it work?
1. Who does it best?
2. Comparative Language
3. Case Series – Immediate effect
4. Brain changes – fMRI
5. RCT 1 year
6. PT after RCT
7. RCT 3 years
1. Who does it best? Analyzing 1 year RCT data
Other therapists 5 years clinical
experience
NPQ > 90%
PNET > 90%
Go through tutorial of
PNET
Have taken 15h CEU
on TNE
Other
PTs
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 28
2. Comparative Language: Some Background
2. Comparative
Language:
Some
Background
2. Comparative Language: Some Background
McGregor AH, Dore CJ, Morris TP, Morris S, Jamrozik K. ISSLS prize winner: Function After Spinal Treatment, Exercise,
and Rehabilitation (FASTER): a factorial randomized trial to determine whether the functional outcome of spinal surgery
can be improved. Spine. Oct 1 2011;36(21):1711-1720.
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 29
Morris S, Morris TP, McGregor AH, Dore CJ, Jamrozik K. Function after spinal treatment, exercise, and rehabilitation:
cost-effectiveness analysis based on a randomized controlled trial. Spine. Oct 1 2011;36(21):1807-1814.
2. Comparative Language: Some Background
• CONCLUSION:
– Cost-effectiveness evidence
does not support use of booklet
over no booklet or rehabilitation
over no rehabilitation for the
postoperative management of
patients after spinal surgery.
2. Comparative Language
• An expert review panel
• Identifying and highlight ‘provocative’ words
• Reviewers were blinded to title and authorship of the booklets.
• Seventeen reviewers from 7 different countries participated
VS.
Louw A, Diener I, Puentedura E. Comparison of Terminology in Patient Education
Booklets for Lumbar Surgery. International Journal of Health Sciences. 2014;2(3):47-
56.
2. Comparative
Language
• Booklet A had almost 3 times as many provocative terms as Booklet B.
• Booklet A had an average of 67.2 provocative terms per reviewer compared to only 22.6 terms for Booklet B.
Louw A, Diener I, Puentedura E.
Comparison of Terminology in Patient
Education Booklets for Lumbar Surgery.
International Journal of Health Sciences.
2014;2(3):47-56.
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 30
3. Case Series – Immediate effect
3. Case Series – Immediate effect • 10 Patients scheduled for Surgery for L-Radiculopathy
– Ave. age 47 years; 7 females
– Ave. duration of leg pain 7 months
– Ave. time till surgery 9.5 days
– Ave. LBP rating 4.6/10
– Ave. leg pain 4.1/10
– Ave. Oswestry 40.8%
– Pain Catastrophization Scale: 25.4
– FABQ-W: 15.8
– FABQ-PA: 18.7
– Pain knowledge: 12/19
– SLR: 50 degrees
– Active trunk flexion 21cm
– Numerous poor beliefs about surgery
Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy:
A case series. International Journal of Spine Surgery. 2015;9(11).
3. Case Series – Immediate effect
Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy:
A case series. International Journal of Spine Surgery. 2015;9(11).
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 31
3. Case Series – Immediate effect
Louw A, Diener I, Puentedura E. The
short term effects of preoperative
neuroscience education for lumbar
radiculopathy: A case series.
International Journal of Spine Surgery.
2015;9(11).
3. Case Series – Immediate effect
• Physical Measurements (after
education only):
– Passive SLR increased 9 degrees
– Active trunk flexion increased 5cm
Louw A, Diener I, Puentedura E. The
short term effects of preoperative
neuroscience education for lumbar
radiculopathy: A case series.
International Journal of Spine Surgery.
2015;9(11).
0
1
2
3
4
5
6
7
8
I feel prepared andready for surgery
I am afraid of theupcoming surgery
I know what toexpect after back
surgery
Back pain aftersurgery is to be
expected
Leg pain aftersurgery is to be
expected
I can control theamount of
postoperative pain
Back surgery will fixmy pain
Before TNE
After TNE
3. Case Series – Immediate effect
Louw A, Diener I, Puentedura E. The
short term effects of preoperative
neuroscience education for lumbar
radiculopathy: A case series.
International Journal of Spine Surgery.
2015;9(11).
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 32
4. Brain changes
– fMRI
Moseley GL. Widespread brain activity during an abdominal
task markedly reduced after pain physiology education: fMRI
evaluation of a single patient with chronic low back pain. Aust
J Physiother. 2005;51(1):49-52.
4. Brain changes – fMRI Louw A, Puentedura EJ, Diener I, Peoples RR.
Preoperative therapeutic neuroscience education for
lumbar radiculopathy: a single-case fMRI report.
Physiotherapy Theory and Practice. Oct
2015;31(7):496-508.
4. Brain changes – fMRI
Louw A, Puentedura EJ, Diener I, Peoples
RR. Preoperative therapeutic neuroscience
education for lumbar radiculopathy: a single-
case fMRI report. Physiotherapy Theory and
Practice. Oct 2015;31(7):496-508.
REST
PERIOD
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 33
4. Brain changes – fMRI
Immediately following TNE straight leg raise increased
by 7° and forward flexion by 8 cm
Louw A, Puentedura EJ, Diener I, Peoples RR.
Preoperative therapeutic neuroscience education
for lumbar radiculopathy: a single-case fMRI report.
Physiotherapy Theory and Practice. Oct
2015;31(7):496-508.
Louw A, Puentedura
EJ, Diener I,
Peoples RR.
Preoperative
therapeutic
neuroscience
education for lumbar
radiculopathy: a
single-case fMRI
report.
Physiotherapy
Theory and
Practice. Oct
2015;31(7):496-508.
4. Brain changes – fMRI
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 34
5. RCT - 1 Year
Louw A, Diener I, Landers MR,
Puentedura EJ. Preoperative pain
neuroscience education for lumbar
radiculopathy: a multicenter
randomized controlled trial with 1-
year follow-up. Spine. Aug 15
2014;39(18):1449-1457.
5. RCT - 1 Year • No statistical significance:
– Back Pain
– Leg Pain
– Catastrophization
– Fear Avoidance
– Pain Knowledge Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain
neuroscience education for lumbar radiculopathy: a multicenter randomized
controlled trial with 1-year follow-up. Spine. Aug 15 2014;39(18):1449-1457.
5. RCT - 1 Year Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education
for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up.
Spine. Aug 15 2014;39(18):1449-1457.
Surgical Experience
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Property of ISPI – not to be copied
without permission 35
5. RCT - 1 Year
45% less on medical tests and treatments…
Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain
neuroscience education for lumbar radiculopathy: a multicenter
randomized controlled trial with 1-year follow-up. Spine. Aug 15
2014;39(18):1449-1457.
6. PT After RCT
Did you attend PT? Louw, Puentedura and Diener – accepted for
publication
Study Design: This was a
multicenter, randomized, controlled
trial (RCT) analyzing physical
therapy (PT) utilization following
lumbar surgery (LS) for
radiculopathy.
Objective: We sought to determine
the referral patterns, utilization and
indications for postoperative PT for
lumbar radiculopathy.
6. PT After
RCT
Louw, Puentedura and
Diener – accepted for
publication
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 36
6. PT After RCT
• 45% of the patients who did not attend PT after LS were of the opinion they would have benefitted of PT after LS
• 62.5% of these patients reported the surgeon not discussing postoperative PT after LS.
Louw, Puentedura
and Diener –
accepted for
publication
6. PT After RCT • Back pain
• Leg pain
• Disability
• Fear-avoidance,
• Pain
catastrophization
• Pain knowledge
• Various LS
beliefs and
experiences
• Before
Surgery
• 1 Month
postop
• 3 Months
postop
• 6 Months
postop
• 12 Months
postop
None of these
predicted who
attended PT
after LS for
radiculopathy
Louw, Puentedura and
Diener – accepted for
publication
7. RCT 3 years
Louw, Puentedura, Landers, Diener
and Zimney 2015 – submitted for
publication
• No statistical significance:
– Back Pain
– Leg Pain
– Catastrophization
– Fear Avoidance
– Pain Knowledge
APTA CSM Anaheim February 17-20, 2016
Property of ISPI – not to be copied
without permission 37
7. RCT 3 years: Cost Louw, Puentedura, Landers, Diener
and Zimney 2015 – submitted for
publication
p = 0.007
1 Year Cost
Difference
45%
3 Year Cost
Difference
60%
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
1 Year 3 Years
3714
5879
5572
9452
EG
UCG
• Ina Diener
• Louis Gifford
• Cesar Fernandez
• John Childs
• Tim Flynn
• Josh Cleland
• Lorimer Moseley
• David Butler
• Merrill Landers
• Steve Schmidt
• ISPI staff and faculty
Thank you & acknowledgements…
1
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