Evaluation of a structured physiotherapy treatment model for patients with lumbar disc herniation

Symptoms from lumbar disc herniation are common in the general population. Many discs heal spontaneously and the patient’s symptoms cease. When people have severe pain and sciatica, the recommendation is to start with physiotherapy treatment and pain medication for at least six to eight weeks before surgery is considered. There is, however, limited evidence relating to the effects of physiotherapy treatment for patients diagnosed with lumbar disc herniation. One common management method for patients with low back pain and sciatica is Mechanical Diagnosis and Therapy (MDT) or the McKenzie method, which aims to eliminate or minimise pain. However, MDT is seldom recommended for patients with disc herniation with a ruptured outer annulus, as the method is not expected to be effective on these patients. The overall aim of this thesis was to evaluate a structured physiotherapy treatment model for patients who qualified for lumbar disc surgery by having severe, long-standing pain and an MRI-verified lumbar disc herniation. Study I evaluated fear-of-movement/kinesiophobia in patients who were treated surgically for lumbar disc herniation. Study II evaluated a structured physiotherapy treatment model in patients who qualified for lumbar disc surgery. Study III described the experience of health among patients three years after treatment with either structured physiotherapy or surgery. Study IV evaluated the occurrence of centralisation of pain in relation to the patients’ disability, self-efficacy and kinesiophobia, after two weeks of McKenzie therapy. Study I showed that, 10-34 months after surgery for disc herniation, half the patients were classified as having kinesiophobia. These patients were more disabled, had more pain, more catastrophising thoughts, more symptoms of depression, lower self-efficacy and poorer health-related quality of life than patients who were not classified as having kinesiophobia. Study II showed that the patients had already improved significantly three months after the structured physiotherapy treatment model in all assessments: disability, leg and back pain, kinesiophobia, health-related quality of life, depression and self-efficacy. The improvement could still be seen at the two-year follow-up. Study III showed that the patients, in the group treated with structured physiotherapy, expressed the most descriptions in feeling of well- being and they were physically active despite symptoms. In the group treated with surgery patients expressed more feeling of ill-being and were anxious and expressed that they avoided physical activity. Study IV showed that 21 of the 41 patients were classified as centralisers after two weeks of structured physiotherapy treatment. These patients had significantly less disability, less leg and back pain, higher self-efficacy and less kinesiophobia three months after treatment was started, compared with non-centralisers. Both the centralisers and the non-centralisers improved statistically over time with regard to several parameters. The overall conclusion from this thesis is that a structured physiotherapy treatment model for patients with pain and disability due to a lumbar disc herniation should be recommended before surgery is considered

Analgesic prescriptions received by patients before commencing the BOA model of care for osteoarthritis : a Swedish national registry study with matched reference and clinical guideline benchmarking

Background and purpose - Swedish clinical guidelines for osteoarthritis (OA) prioritize patient education, exercise, and-if necessary-weight reduction before considering adjunct pharmacological intervention. Contrariwise, we investigated the proportion and type of dispensed analgesic prescriptions in Sweden received by patients during 3 years before commencing non-pharmacological primary care interventions for OA (2008-2016) compared with the general population. Furthermore, we analyzed the proportion of analgesic prescriptions dispensed before (2008-2012) compared with after (2012-2016) guideline publication in terms of concordance with clinical guideline recommendations. Patients and methods - Patients with hip or knee OA (n = 72,069) from the Better Management of OA national quality register receiving non-pharmacological interventions in primary care between 2008 and 2016 were included (OA cohort). An age, sex, and residence matched reference cohort (n = 216,207) was formed from the Swedish Total Population Register. Based on a period 3 years prior to inclusion in the OA cohort, Swedish Prescribed Drug Register data was linked to both the OA and reference cohorts. Results - Compared with the reference cohort, a distinctly larger proportion of the OA cohort had dispensed prescriptions for most types of analgesics, increasing exponentially each year prior to commencing non-pharmacological intervention. Since guideline publication, the proportion of the OA cohort having no dispensed prescription analgesics prior to non-pharmacological primary care intervention concordantly increased by 5.0% (95% CI 4.2-5.9). Furthermore, dispensed prescriptions concordantly decreased for non-selective NSAIDs -8.6% (CI -9.6 to -7.6), weak opioids -6.8% (CI -7.7 to -5.9), glucosamine -9.5% (CI -9.8 to -8.8). and hyaluronic acid -1.6% (CI -1.8 to -1.5) but discordantly increased for strong opioids 2.8% (CI 2.1-3.4) and glucocorticoid intra-articular injection for hip OA 2.1% (CI 1.0-3.1). Interpretation - In Sweden, dispensed prescription of analgesics commonly occurred before initiating non-pharmacological primary care interventions for OA but reduced modestly after guideline publication, which prioritizes non-pharmacological before pharmacological interventions. Additional modest improvements occurred in the stepped-care prioritization of analgesic prescription types. However, future strategies are required to curb an increase of strong opioids prescription for OA and glucocorticoid intra-articular injection for hip OA