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Pre-surgery physiotherapy and pain thresholds in patients with degenerative lumbar spine disorders
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Patients scheduled for spinal surgery often experience long duration of pain, which may influence the pain-regulation system, function and health and have an impact on post-surgery outcome. Prehabilitation potentially augments functional capacity before surgery, which may have beneficial effects after surgery.

Aim: The overall aim of the thesis is to study pre-surgery physiotherapy and somatosensory function in patients with degenerative lumbar spine disorders and to explore the patients’ experiences of pre-surgery physiotherapy.

Methods: Somatosensory function was measured with quantitative sensory testing (QST). Pre-surgery physiotherapy was evaluated with patient-reported outcome measures (n = 197). Patients’ experiences of how symptoms are explained and their experiences of the influences on back-related health after pre-surgery physiotherapy were explored.

Results: Half of the patients reported back or leg pain for more than 2 years. On a group level, the somatosensory profiles were within the reference range. On an individual level, an altered somatosensory profile was found in 23/105 patients, these were older, more often women, and reported higher pain, larger pain distribution and worse SF-36 MCS (mental health component summary). Patients with disc herniation, more sensitive to pressure pain in the hand presurgery, was associated with poorer function, self-efficacy, anxiety and depression score pre-surgery, worse function, self-efficacy and leg pain 3 months post-surgery and worse health related quality of life, self-efficacy, depression score 1 year postsurgery. The results for sensitivity for cold pain were similar, except that it even was associated with poorer function and pain 1 year post-surgery. The pre-surgery physiotherapy group had less back pain, better function, health, self-efficacy, fear avoidance score, depression score and physical activity level than the waiting-list group after the pre-surgery intervention. The effects were small. Both groups improved significantly after surgery, with no differences between groups, except that the higher physical activity level in the physiotherapy group remained at the 1-year follow-up. Only 58% of the patients reported a minimum of one visit for rehabilitation during the 1 year preceding the decision to undergo surgery. Patients experienced that pre-surgery physiotherapy had influenced symptoms, physical function, coping, well-being and social functioning to various degrees. Pre-surgery physiotherapy was experienced as a tool for reassurance and an opportunity to reflect about treatment and lifestyle. The patients mainly used biomedical explanatory models based on image reports to explain their backrelated symptoms. Both broader and more narrow, as well as lack of explanations of symptoms emerged. Further, wanting and sometimes struggling to be wellinformed about symptoms and interventions were described.

Conclusions: Being more sensitive to pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery, was associated with poorer function, pain and health at post-surgery in patients with disc herniation. Pre-surgery physiotherapy decreased pain, fear avoidance, improved health related quality of life; and it decreased the risk of a worsening in psychological well-being before surgery. The improvements were small, and improvements after surgery were similar for both groups. At the 1-year follow-up, the physiotherapy group still had a higher activity level than the waiting list group. The pre-surgery physiotherapy was well tolerated. Patients’ reported experiences also illustrates the influence on function, pain and health. Patients experienced that pre-surgery physiotherapy provided reassurance and gave time to reflect on treatments and lifestyle. Symptoms were mainly described in line with a biomedical explanatory model. Those using a broader explanation were confident that physiotherapy and self-management could influence their back-related symptoms.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. , p. 86
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1629
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:liu:diva-150553DOI: 10.3384/diss.diva-150553ISBN: 9789176852767 (print)OAI: oai:DiVA.org:liu-150553DiVA, id: diva2:1242213
Public defence
2018-09-21, Berzeliussalen, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2018-08-27 Created: 2018-08-27 Last updated: 2019-09-30Bibliographically approved
List of papers
1. Altered somatosensory profile according to quantitative sensory testing in patients with degenerative lumbar spine disorders scheduled for surgery
Open this publication in new window or tab >>Altered somatosensory profile according to quantitative sensory testing in patients with degenerative lumbar spine disorders scheduled for surgery
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2017 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 18, article id 264Article in journal (Refereed) Published
Abstract [en]

Background: Somatosensory profiling in affected and non-affected body regions can strengthen our insight regarding the underlying pain mechanisms, which can be valuable in treatment decision making and to improve outcomes, in patients with degenerative lumbar spine disorders pre-surgery. The aim was to describe somatosensory profiles in patients with degenerative lumbar spine disorders, to identify the proportion with altered somatosensory profile, and to analyze demographic characteristics, self-reported function, pain, and health pre- and 3 months post-surgery. Methods: In this prospective cohort study in a Spine Clinic, 105 patients scheduled for surgery for spinal stenosis, disc herniation, degenerative disc disease, or spondylolisthesis were consecutively recruited. Exclusion criteria were; indication for acute surgery or previous surgery at the same spinal level or severe grade of pathology. Quantitative sensory testing (QST) and self-reported function, pain, and health was measured pre- and 3 months post-surgery. The somatosensory profile included cold detection threshold, warmth detection threshold, cold pain threshold, heat pain threshold and pressure pain threshold in affected and non-affected body regions. Results: On a group level, the patients somatosensory profiles were within the 95% confidence interval (CI) from normative reference data means. On an individual level, an altered somatosensory profile was defined as having two or more body regions (including a non-affected region) with QST values outside of normal ranges for reference data. The 23 patients (22%) with altered somatosensory profiles, with mostly loss of function, were older (P = 0.031), more often female (P = 0.005), had higher back and leg pain (P = 0.016, 0.020), lower mental health component summary score (SF 36 MCS) (P = 0.004) and larger pain distribution (P = 0.047), compared to others in the cohort. Post-surgery there was a tendency to worse pain, function and health in the group with altered somatosensory profile pre-surgery. Conclusions: On a group level, patients with degenerative lumbar spine disorders scheduled for surgery were within normal range for the QST measurements compared to reference values. On an individual level, an altered somatosensory profile outside of normal range in both affected and non-affected body regions occurred in 22% of patients, which may indicate disturbed somatosensory function. Those patients had mostly loss of sensory function and had worse self-reported outcome pre-surgery, compared to the rest of the cohort. Future prospective studies are needed to further examine whether these dimensions can be useful in predicting post-surgery outcome and guide need of additional treatments.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2017
Keywords
Disc herniation; Spinal stenosis; Spondylolisthesis; Degenerative disc disease; Spine surgery; Quantitative sensory testing; Outcome
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-139285 (URN)10.1186/s12891-017-1581-6 (DOI)000403494900001 ()28623897 (PubMedID)
Note

Funding Agencies|Swedish Research Council [521-2019-3578]; Faculty of Medicine and Health, Linkoping University; County Council of Ostergotland, Linkoping, Sweden

Available from: 2017-07-07 Created: 2017-07-07 Last updated: 2018-08-28
2. Association between pain sensitivity in the hand and outcomes after surgery in patients with lumbar disc herniation or spinal stenosis.
Open this publication in new window or tab >>Association between pain sensitivity in the hand and outcomes after surgery in patients with lumbar disc herniation or spinal stenosis.
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2017 (English)In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 26, no 10, p. 2581-2588Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To investigate the association between pain sensitivity in the hand pre-surgery, and patient-reported outcomes (PROs) in function, pain and health pre- and post-surgery in patients with disc herniation or spinal stenosis.

METHODS: This is a prospective cohort study with 82 patients. Associations between pressure-, cold- and heat pain threshold (PPT, CPT, HPT) in the hand pre-surgery and Oswestry, VAS pain, EQ-5D, HADS, and Self-Efficacy Scale, pre- and three months post-surgery; were investigated with linear regression.

RESULTS: Patients with disc herniation more sensitive to pressure pain pre-surgery showed lower function and self-efficacy, and higher anxiety and depression pre-surgery, and lower function, and self-efficacy, and higher pain post-surgery. Results for cold pain were similar. In patients with spinal stenosis few associations with PROs were found and none for HPT and PROs.

CONCLUSIONS: Altered pain response in pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery had associations with higher pain, lower function and self-efficacy post-surgery in patients with disc herniation.

Place, publisher, year, edition, pages
Springer, 2017
Keywords
Disc herniation, Quantitative sensory testing, Spinal stenosis, Spinal surgery, Widespread pain
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-136688 (URN)10.1007/s00586-017-4979-9 (DOI)000412841000013 ()28168345 (PubMedID)2-s2.0-85011710070 (Scopus ID)
Note

Funding agencies: Swedish Research Council [521-2019-3578]; Faculty of Medicine and Health, Linkoping University; County Council of Ostergotland, Linkoping, Sweden

Available from: 2017-05-12 Created: 2017-05-12 Last updated: 2018-08-27Bibliographically approved
3. PREPARE: presurgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial
Open this publication in new window or tab >>PREPARE: presurgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial
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2018 (English)In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 18, no 8, p. 1347-1355Article in journal (Refereed) Published
Abstract [en]

Background Context

Surgery because of disc herniation or spinal stenosis results mostly in large improvement in the short-term, but mild to moderate improvements for pain and disability at long-term follow-up. Prehabilitation has been defined as augmenting functional capacity before surgery, which may have beneficial effect on outcome after surgery.

Purpose

The aim was to study if presurgery physiotherapy improves function, pain, and health in patients with degenerative lumbar spine disorder scheduled for surgery.

Study Design

A single-blinded, two-arm, randomized controlled trial (RCT).

Patient Sample

A total of 197 patients were consecutively included at a spine clinic. The inclusion criteria were patients scheduled for surgery because of disc herniation, spinal stenosis, spondylolisthesis, or degenerative disc disease (DDD), 25–80 years of age.

Outcome Measures

Primary outcome was Oswestry Disability Index (ODI). Secondary outcomes were pain intensity, anxiety, depression, self-efficacy, fear avoidance, physical activity, and treatment effect.

Methods

Patients were randomized to either presurgery physiotherapy or standardized information, with follow-up after the presurgery intervention as well as 3 and 12 months post surgery. The study was funded by regional research funds for US$77,342. No conflict of interest is declared.

Results

The presurgery physiotherapy group had better ODI, visual analog scale (VAS) back pain, EuroQol-5D (EQ-5D), EQ-VAS, Fear Avoidance Belief Questionnaire-Physical Activity (FABQ-PA), Self-Efficacy Scale (SES), and Hospital Anxiety and Depression Scale (HADS) depression scores and activity level compared with the waiting-list group after the presurgery intervention. The improvements were small, but larger than the study-specific minimal clinical important change (MCIC) in VAS back and leg pain, EQ-5D, and FABQ-PA, and almost in line with MCIC in ODI and Physical Component Summary (PCS) in the physiotherapy group. Post surgery, the only difference between the groups was higher activity level in the physiotherapy group compared with the waiting-list group.

Conclusions

Presurgery physiotherapy decreases pain, risk of avoidance behavior, and worsening of psychological well-being, and improves quality of life and physical activity levels before surgery compared with waiting-list controls. These results were maintained only for activity levelspost surgery. Still, presurgery selection, content, dosage of exercises, and importance of being active in a presurgery physiotherapy intervention is of interest to study further to improve long-term outcome.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Disc herniation, Function, Physiotherapy, Spinal stenosis, Stratification, Surgery
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-147620 (URN)10.1016/j.spinee.2017.12.009 (DOI)000443585000006 ()29253630 (PubMedID)2-s2.0-85044627865 (Scopus ID)
Available from: 2018-04-27 Created: 2018-04-27 Last updated: 2019-05-01Bibliographically approved
4. Patients' experiences of how symptoms are explained and influences on back-related health after pre-surgery physiotherapy: A qualitative study
Open this publication in new window or tab >>Patients' experiences of how symptoms are explained and influences on back-related health after pre-surgery physiotherapy: A qualitative study
2019 (English)In: Musculoskeletal science & practice, ISSN 2468-7812, Vol. 40, p. 34-39Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Since the pre-surgery phase is a new setting for physiotherapy, exploring patients' experiences might contribute to new insights for future development of care in patients with degenerative lumbar spine disorders.

OBJECTIVES: To describe patients' experiences of how symptoms are explained, and their experiences of the influences on back-related health after pre-surgery physiotherapy.

DESIGN: Explorative qualitative design using semi-structured interviews analysed with content analysis.

PARTICIPANTS: Eighteen patients with degenerative lumbar spine disorder scheduled for surgery, participated in pre-surgery physiotherapy.

FINDINGS: Five categories were identified: Influences on symptoms, physical function and sleep; Influences on coping and well-being; Explanations of back-related symptoms and wanting to be well-informed; Influence on social functioning; The ability of the model of care to influence reassurance and prevention.

CONCLUSION: Improvements in back-related health in all the biopsychosocial dimensions emerged. Even those who expressed no symptom improvements, felt better performing exercises than being inactive, and exercises improved their frame of mind, a useful experience in possible low back pain recurrences. Pre-surgery physiotherapy provided reassurance and gave time to reflect on treatments and lifestyle. Despite pre-surgery physiotherapy, back-related symptoms were mainly described in line with a biomedical explanatory model. Those using broader explanations were confident that physiotherapy and self-management could influence their symptoms. Suggesting more emphasis on explanatory models suitable for surgery, pre- and post-surgery physiotherapy and self-management in the professionals' dialogue with patients.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Content analysis, Exercise therapy, Patients' experience, Physiotherapy, Qualitative study, Spinal surgery
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-154072 (URN)10.1016/j.msksp.2019.01.003 (DOI)000460108500005 ()30665046 (PubMedID)2-s2.0-85060104361 (Scopus ID)
Funder
Region Östergötland
Note

This article had the status submitted when included in the thesis with the title "Pre-surgery physiotherapy and pain thresholds in patients with degenerative lumbar spine disorders" and the permanent link http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-150553.

Funding agencies: County Council of Ostergotland, Linkoping, Sweden

Available from: 2019-01-28 Created: 2019-01-28 Last updated: 2019-03-20Bibliographically approved

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