Inter-rater reliability of three standardized functional tests in patients with low back pain

<p>Abstract</p> <p>Background</p> <p>Of all patients with low back pain, 85% are diagnosed as "non-specific lumbar pain". Lumbar instability has been described as one specific diagnosis which several authors have described as delayed muscular responses, impaired postural control as well as impaired muscular coordination among these patients. This has mostly been measured and evaluated in a laboratory setting. There are few standardized and evaluated functional tests, examining functional muscular coordination which are also applicable in the non-laboratory setting. In ordinary clinical work, tests of functional muscular coordination should be easy to apply. The aim of this present study was to therefore standardize and examine the inter-rater reliability of three functional tests of muscular functional coordination of the lumbar spine in patients with low back pain.</p> <p>Methods</p> <p>Nineteen consecutive individuals, ten men and nine women were included. (Mean age 42 years, SD ± 12 yrs). Two independent examiners assessed three tests: "single limb stance", "sitting on a Bobath ball with one leg lifted" and "unilateral pelvic lift" on the same occasion. The standardization procedure took altered positions of the spine or pelvis and compensatory movements of the free extremities into account. The inter-rater reliability was analyzed by Cohen's kappa coefficient (κ) and by percentage agreement.</p> <p>Results</p> <p>The inter-rater reliability for the right and the left leg respectively was: for the single limb stance very good (κ: 0.88–1.0), for sitting on a Bobath ball good (κ: 0.79) and very good (κ: 0.88) and for the unilateral pelvic lift: good (κ: 0.61) and moderate (κ: 0.47).</p> <p>Conclusion</p> <p>The present study showed good to very good inter-rater reliability for two standardized tests, that is, the single-limb stance and sitting on a Bobath-ball with one leg lifted. Inter-rater reliability for the unilateral pelvic lift test was moderate to good. Validation of the tests in their ability to evaluate lumbar stability is required.</p

Function after spinal treatment, exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery

Background: The life-time incidence of low back pain is high and diagnoses of spinal stenosis and disc prolapse are increasing. Consequently, there is a steady rise in surgical interventions for these conditions. Current evidence suggests that while the success of surgery is incomplete, it is superior to conservative interventions. A recent survey indicates that there are large differences in the type and intensity of rehabilitation, if any, provided after spinal surgery as well as in the restrictions and advice given to patients in the post-operative period. This trial will test the hypothesis that functional outcome following two common spinal operations can be improved by a programme of post-operative rehabilitation that combines professional support and advice with graded active exercise and/or an educational booklet based on evidence-based messages and advice.Methods/Design: The study design is a multi-centre, factorial, randomised controlled trial with patients stratified by surgeon and operative procedure. The trial will compare the effectiveness and cost-effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression, each compared with "usual care" using a 2 x 2 factorial design. The trial will create 4 sub-groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The trial aims to recruit 344 patients, which equates to 86 patients in each of the four sub-groups. All patients will be assessed for functional ability (through the Oswestry Disability Index - a disease specific functional questionnaire), pain (using visual analogue scales), and satisfaction pre-operatively and then at 6 weeks, 3, 6 and 9 months and 1 year post-operatively. This will be complemented by a formal analysis of cost-effectiveness.Discussion: This trial will determine whether the outcome of spinal surgery can be enhanced by either a postoperative rehabilitation programme or an evidence-based advice booklet or a combination of the two and as such will contribute to our knowledge on how to manage spinal surgery patients in the post-operative period

Early neuromuscular customized training after surgery for lumbar disc herniation: a prospective controlled study

A prospective and controlled study of training after surgery for lumbar disc herniation (LDH). The objective was to determine the effect of early neuromuscular customized training after LDH surgery. No consensus exists on the type and timing of physical rehabilitation after LDH surgery. Patients aged 15–50 years, disc prolapse at L4–L5 or L5–S1. Before surgery, at 6 weeks, 4, and 12 months postoperatively, the following evaluations were performed: low back pain and leg pain estimated on a visual analog scale, disability according to the Roland–Morris questionnaire (RMQ) and disability rating index (DRI). Clinical examination, including the SLR test, was performed using a single blind method. Consumption of analgesics was registered. Twenty-five patients started neuromuscular customized training 2 weeks after surgery (early training group=ETG). Thirty-one patients formed a control group (CG) and started traditional training after 6 weeks. There was no significant difference in pain and disability between the two training groups before surgery. Median preoperative leg pain was 63 mm in ETG and 70 mm in the CG. Preoperative median disability according to RMQ was 14 in the ETG and 14.5 in the CG. Disability according to DRI (33/56 patients) was 5.3 in the ETG vs. 4.6 in the CG. At 6 weeks, 4 months, and 12 months, pain was significantly reduced in both groups, to the same extent. Disability scores were lower in the ETG at all follow-ups, and after 12 months, the difference was significant (RMQ P=.034, DRI P=.015). The results of the present study show early neuromuscular customized training to have a superior effect on disability, with a significant difference compared to traditional training at a follow-up 12 months after surgery. No adverse effects of the early training were seen. A prospective, randomized study with a larger patient sample is warranted to ultimately demonstrate that early training as described is beneficial for patients undergoing LDH surgery

Rehabilitation following surgery for lumbar spinal stenosis

Abstract Background Lumbar spinal stenosis is a common cause of back pain among older people that can also give rise to pain in the buttock, thigh or leg, particularly when walking. There are several possible treatments, of which surgery appears to be best at restoring function and reducing pain. The outcome of surgery however falls well short of ideal and a sizeable proportion of patients do not regain good function. Importantly, there is no accepted evidence-based approach to post-operative care, which is what has prompted this review. Objectives This Cochrane Review was designed, to establish whether the outcome of surgery for lumbar stenosis can be improved by active rehabilitation programmes and if such programmes are superior to usual post-operative care. Active rehabilitation includes any group or therapist led intervention to improve functional status through a programme of exercises or educational material encouraging activity. Search methods A comprehensive search of CENTRAL (The Cochrane Library, most recent issue), the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL, and PEDRO since their first issues was conducted on 12 January 2012. Selection criteria Only RCTs that compared the effectiveness of active rehabilitation with usual care in adults (>18 year olds) with confirmed lumbar spinal stenosis, who had undergone spinal decompressive surgery (with or without fusion) for the first time, were considered in this review. Data collection and analysis Two review authors independently extracted data for the included trials using a pre-developed form. Where necessary the authors of the original trials were contacted to request additional unpublished data. The outcome measures and interventions of the trials were assessed to ensure the baseline characteristics of participants were clinically homogeneous. The clinical relevance of each study was independently assessed, using the five questions recommended by the Cochrane Back Review Group (CBRG), and the risk of bias within the studies was assessed using the CBRG criteria. The results of the individual studies were pooled in a meta-analysis where appropriate. For continuous outcomes, the mean difference (MD) was calculated when the same measurement scales were used in all studies and the standardised mean difference (SMD) when different measurement scales were used. Where the outcome data were skewed meta-analysis was performed on the log-scale and results were converted back to the original scale. A fixed-effect model was used to measure the treatment effect where there was no substantial evidence of statistical heterogeneity. If substantial statistical heterogeneity was detected, a random-effects model was used. The primary outcome measure was functional status measured by a back-specific functional scale. Secondary outcomes included measures of leg pain and low back pain, and global improvement / general health. These were reported and analysed separately for short- and long-term outcomes. Statistical significance as well as clinical relevance of outcomes was considered. The GRADE approach was used to determine the overall quality of evidence for each outcome using five criteria, where evidence is ranked from high to very low quality, depending on the number of criteria met. Results The searches yielded 1726 results, and in total three studies were included in the review and meta-analysis. Outcomes in the short-term (within 6 months post-operative): In the short-term there is moderate quality evidence from three RCTs (N= 340) that active rehabilitation is more effective than usual care for functional status and low quality evidence that rehabilitation is more effective for reported low back pain. In contrast, low quality evidence suggests rehabilitation is no more effective than usual care for leg pain (N=340). Low quality evidence from two RCTs (N=238) indicates that rehabilitation is no more effective than usual care for general health. Outcomes in the long-term (at 12 months post-operative): In the long-term there is moderate quality evidence from three RCTs (N= 373 that rehabilitation is more effective than usual care for functional status and reported low back pain. Moderate quality evidence suggests that rehabilitation is more effective than usual care for leg pain (N=373). In contrast low quality evidence suggests that rehabilitation is no more effective than usual care for general health (evidence from two studies, N=273). Authors' conclusions The evidence suggests that active rehabilitation is more effective than usual care for improving both short and long term (back-related) functional status. Similar findings were noted for other secondary outcomes including; short-term improvements in low back pain and long-term improvement in both low back pain and leg pain. The clinical relevance of these statistically significant effects is medium to small. Our evaluation is limited by the small number of relevant studies identified. Further research is required to provide higher quality evidence, and to consider other relevant outcomes such as work participation. Plain language summary Can active rehabilitation improve the outcome of surgery for spinal stenosis? Spinal stenosis is a common age-related condition of the spine (back) that leads to back and leg pain. Surgery is the treatment of choice for many patients, but we know that their ability to carry out everyday tasks (functional recovery) following surgery is not ideal, although leg pain does improve for most patients. This review wished to find out whether active rehabilitation after surgery could improve the ability of patients to carry out everyday tasks when compared to the usual post-operative care. We found that very little work had been done in this area; only 3 studies were suitable for inclusion. Each involved a rehabilitation programme between 30 to 90 minutes long, either once or twice weekly, starting 6 to 12 weeks after surgery. We found that active rehabilitation is helpful following surgery, providing modest improvements in both function and low back pain in both the short-term (within 6 months of surgery), and long-term (at 12 months)

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

Study Design. This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure.Objective. This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with graded active exercise commencing 6 weeks after surgery and/or an educational booklet based on evidence-based messages and advice received at discharge from hospital, each compared with usual care.Summary of Background Data. Surgical interventions on the spine are increasing, and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management, functional outcome, and patient satisfaction are not optimal.Methods. The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with "usual care" using a 2 x 2 factorial design, randomizing patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analog scale measures of back and leg pain.Results. Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks, 3, 6, 9 and 12 months postoperatively. Twelve months postoperatively the observed effect of rehabilitation on ODI was -2.7 (95% CI: -6.8 to 1.5) and the effect of booklet was 2.7 (95% CI: -1.5 to 6.9).Conclusion. This study found that neither intervention had a significant impact on long-term outcome