The correlation of the self-reported Leeds assessment of neuropathic symptoms and signs score, clinical neurological examination findings and magnetic resonance imaging findings in patients with Lumbo-sacral radiculopathy

Philosophiae Doctor - PhDLumbo-sacral radiculopathy (LSR) is clinically defined as low back and referred leg symptoms accompanied by an objective sensory and/or motor deficit due to nerve root compromise. LSR is a common condition encountered by physiotherapists in clinical practice and the assessment and diagnosis remains a challenge owing to the complex anatomy of the lumbo-sacral spine segment and the various differentials. Moreover, LSR imposes a significant impact on patients’ health, functional ability, socio-economic status and quality of life. There are several diagnostic tools and procedures which are commonly utilised in practice, including diagnostic neuropathic pain screening questionnaires, clinical neurological tests, electro-diagnostics and imaging. However, the diagnostic utility and correlation of these tests have not been fully explored and remains debatable among clinicians and researchers in the fields of musculo-skeletal health and neurology. The aim of this study was to determine a correlation of the S-LANSS score, clinical neurological examination (CNE) findings and magnetic resonance imaging (MRI) reports in the diagnosis of LSR among patients who presented with low back and referred leg symptoms. The study was conducted in three phases. In phase one, two systematic literature reviews were conducted; firstly, to establish the evidence-based accuracy of CNE in diagnosing LSR, and secondly, to establish the evidence-based accuracy of MRI in diagnosing LSR. In both systematic literature reviews, the diagnostic tests accuracy (DTA) protocol was used in planning, design and execution of literature search, selection of relevant studies, quality assessment, data analysis and presentation of the results. In phase two, clinical validation of an adopted S-LANSS scale and lumbar MRI reporting protocol were established, and a standardised evidence based lumbar CNE protocol developed.The face and content validity of the original S-LANSS score was established among a sample of Kenyan physiotherapists and patients who presented with low back and referred leg symptoms, using both quantitative and qualitative research designs. This was followed by a test-re-test reliability study on the adapted version of the S- LNASS score. The face and content validity of the adopted lumbar MRI reporting protocol was established among a sample of Kenyan radiologists followed by an inter-rater reliability. An evidence-based lumbar CNE protocol was developed; standardised and inter-examiner reliability was also examined among a sample of Kenyan physiotherapists. Finally, in phase three, a cross-sectional blinded validity study was conducted in six different physiotherapy departments. Participants (patients, physiotherapists and radiologists) were recruited using strict in- and exclusion criteria and data was collected using a pain and demographic questionnaire, the S-LANSS scale, the CNE protocol, the Oswestry Disability Index (ODI) and the MRI lumbar spine reporting protocol. Data was captured, cleaned and analysed using SPSS version 21. Descriptive analysis was done using frequencies, means and percentages, while inferential analysis was conducted using Spearman’s rank correlation coefficient test r to establish the correlation between the diagnostic tests. Cross tabulations, receiver operating curves (ROC) and scatter plots were used to establish the sensitivity and/or specificity of S-LANSS scale and individual CNE tests as defined by MRI. In phase three, which formed the main study of the research project, a total of 102 participants were recruited in this study with a gender distribution of 57% females and 43% males. The majority (67%) had neuropathic pain according to the S-LANSS scale and their pain intensity ranged from moderate (4-6) to severe (7-9) as recorded on a Numeric Pain rating Scale (NPRS), and was more common among manual workers. Similarly, patients whose pain had a neuropathic component had moderate to severe disability. The S-LANSS scale and lower limb neuro-dynamic tests were the most sensitive tests 0.79 and 0.75 respectively, while deep tendon reflexes were the most specific tests (0.87). The S-LANSS and CNE correlated fairly but significantly with MRI (r=0.36, P=0.01).LSR is a common condition and its assessment and diagnosis remains a clinical challenge among physiotherapists. MRI is a high-cost diagnostic tool but is being used by many clinicians in making decisions regarding the management of patients. Rapid and low-cost neuropathic pain screening by the use of the S-LANSS scale, together with use of evidence-based CNE of neuro-conduction and neuro-dynamic tests may be used in confirming nerve-root related MRI findings. These may be used in making a decision on whether to manage a patient conservatively using pharmacological agents and manual physiotherapy and therapeutic exercise, or consider surgery in the initial management of patients with clinical suspicion of LSR. This is especially valuable in the resource-poor settings like Kenya and other sub-Saharan African countries where MRI is costly or unavailable

The prevalence of risk factors for non-communicable diseases among people living in Mombasa, Kenya

Magister Scientiae (Physiotherapy) - MSc(Physio)Chronic non-communicable diseases, including cardio-vascular diseases and stroke, cancer, type 2 diabetes and chronic pulmonary disorders, are rapidly emerging as leading causes of morbidity and premature mortalities globally. The majority of the populations worldwide have experienced major transformations in disease profiles and health status characterized by a shift from infectious diseases and nutritional deficiencies to a predominance of chronic diseases of lifestyle. This epidemiological transition is regarded as an outcome of the environmental and socioeconomic changes following urbanization.Common behavioral health risk factors, such as smoking, risky alcohol consumption,sedentarism, overweigh/obesity and hypertension, have consistently been attributed to the development of chronic non-communicable diseases among populations.This thesis seeks to describe the epidemiology of the major common risk factors for noncommunicable diseases among people living in Mombasa, Kenya. The study responds to the WHO’S recommendations on comprehensive and continuous risk factor surveillance as an essential component of the public health information system and a vital health promoting strategy in the control and prevention of non-communicable diseases.A cross-sectional study design using the WHO STEPwise protocol was employed.Convenient stratification of the Mombasa population was done according to gender, age and setting categories. Using the Yamane formula n = N/1+ N(e²), a sample of 500 participants aged 15 to 70 years was arrived at. The researcher then conveniently selected public high schools, tertiary institutions, workplaces and a marketplace as the study settings.The WHO STEPS instrument (Core and Expanded Version 1.4) was used for data collection. Step 1 involved gathering information on socio-demographic characteristics and health-related behaviors of the participants using close-ended structured questions. Step involved the taking of simple anthropometrical measurements pertaining to height, weight, waist circumference, blood pressure and pulse rate.Data were captured, cleaned and analyzed using the Statistical Analysis System (SAS) and SPSS version 16.0. Chi-square and Spearman correlation tests were used to determine associations between socio-demographic variables and behavioral health risk factors.The results indicated that 61% of the study participants possessed at least one of the investigated risk factors. 17% of the participants had a multiple risk factor profile, with 54% more females having a higher mean risk factor score compared to 46% of their male counterparts.Physical inactivity, hypertension and overweight/obesity were the most common registered risk factors, accounting respectively for 42%, 24% and 11%. Physical inactivity and hypertension formed the commonest cluster of multiple risk factor patterns; they co-occurred in 68% of the participants with a multiple risk factor profile.Increasing age, female gender and a low level of educational attainment were factors seen to be significantly associated with the development of risk factors for non-communicable diseases among the participants. It was observed that the burden of risk factors was unequally distributed among Mombasa residents; intervention programs based on our findings should therefore be used to ensure effectiveness. Future studies using nationally representative samples are further suggested to provide a more comprehensive analysis of a national risk factor profile

A prevalence of running-related injuries among professional endurance runners in the Rift Valley, Kenya

Background: Injuries related to endurance running have attracted attention as the sport has become more competitive, and as athletes seek to improve their performance. Consequently, endurance runners are increasingly becoming more susceptible to lower extremity running injuries. Objectives: The aim of this study was to establish the prevalence of running-related injuries among professional endurance runners in the Rift Valley, Kenya. Methods: We used a cross-sectional survey design targeting professional endurance runners who had participated in both local and international running competitions. The sample size consisted of 209 respondents selected through stratified and simple random sampling techniques, of which 167 participated in the study. A self-administered questionnaire was used to collect data on the prevalence of injuries among the endurance runners. The data were analysed using descriptive statistics. Results: The prevalence of running injuries was 63% (n=106). The prevalence among males (n=64; 69%) was higher in comparison with that of females (n=42; 57%). The posterior thigh was the most common site for injuries among the athletes (n=87; 52%), followed by the lower back (n=78; 47%) and ankle (n=63; 38%). Conclusion: The prevalence of running-related injuries was high among professional Kenyan endurance runners compared to other populations. These findings therefore form the basis of future research to explore the mechanisms behind the injuries and the feasibility of targeted injury prevention programmes

Risk factors for chronic non communicable diseases in Mombasa, Kenya: epidemiological study using WHO stepwise approach

OBJECTIVE: To describe the prevalence and distribution patterns of the major common risk factors for non communicable diseases among the people living in Mombasa, Kenya. METHODS: Using the WHO STEPwise approach, risk factors for non communicable diseases were analyzed for 305 people aged between 13 to 67 years. The study sample was arrived at through convenient stratification of the population according to age and setting followed by random selection of the participants. RESULTS: The most common individual risk factors registered were physical inactivity, hypertension and overweight/obesity accounting for 42%, 24% and 11% of the sample respectively. Participants who possessed a single risk factor profile were 42% and those who had multiple risk factors were approximately 17%. Hypertension and physical inactivity were the most common multiple risk factor pattern possessed by 7.5% of the participants who had at least one of the investigated risk factors for CNCDs. Socio-demographic characteristics including male gender, increasing age, being a student and low socio-economic status were found to be positive predictors of CNCDs CONCLUSION: The burden of CNCDs risk factors is unequally distributed among Mombasa residents. The poorest quintile posses the worst risk factor profile compared to their privileged counterparts. The implementation of WHO STEPwise approach was feasible since it revealed a comprehensive picture of the at-risk groups thus forming a vital baseline framework for target specific and cost-effective CNCDs control and prevention interventions.Web of Scienc

Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: a systematic literature review

BACKGROUND: Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate treatment of patients resulting in poor health outcomes, exacerbating this already debilitating condition. This review evaluated 12 primary diagnostic accuracy studies that specifically assessed the performance of various individual and grouped clinical neurological tests in detecting nerve root impingement, as established in the current literature. METHODS: Eight electronic data bases were searched for relevant articles from inception until July 2016. All primary diagnostic studies which investigated the accuracy of clinical neurological test (s) in diagnosing lumbar radiculopathy among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the ‘Quality Assessment of Diagnostic tests Accuracy Studies’ criteria. RESULTS: A total of 12 studies which investigated standard components of clinical neurological examination of (sensory, motor, tendon reflex and neuro-dynamics) of the lumbo-sacral spine were included. The mean inter-observer agreement on quality assessment by two independent reviewers was fair (k = 0.3 – 0.7). The diagnostic performance of sensory testing using MR imaging as a reference standard demonstrated a sensitivity (confidence interval 95%) 0.61 (0.47-0.73) and a specificity of 0.63 (0.38-0.84). Motor tests sensitivity was poor to moderate, ranging from 0.13 (0.04-0.31) to 0.61 (0.36-0.83). Generally, the diagnostic performance of reflex testing was notably good with specificity ranging from (confidence interval 95%) 0.60 (0.51-0.69) to 0.93 (0.87-0.97) and sensitivity ranging from 0.14 (0.09-0.21) to 0.67 (0.21-0.94). Femoral nerve stretch test had a high sensitivity of (confidence interval 95%) 1.00 (0.40-1.00) and specificity of 0.83 (0.52-0.98) while SLR test recorded a mean sensitivity of 0.84 (0.72-0.92) and specificity of 0.78 (0.67-0.87). CONCLUSION: There is a scarcity of studies on the diagnostic accuracy of clinical neurological examination testing. Furthermore there seem to be a disconnect among researchers regarding the diagnostic utility of lower limb neurodynamic tests which include the Straight Leg Raise and Femoral Nerve tests for sciatic and femoral nerve respectively. Whether these tests are able to detect the presence of disc herniation and subsequent nerve root compression or hyper-sensitivity of the sacral and femoral plexus due to mechanical irritation still remains debatable.IS

Translation and adaptation of the stroke-specific quality of life scale into Swahili

Background: Stroke care requires a patient-centred, evidence-based and culturally appropriate approach for better patient clinical outcomes. Quality of life necessitates precise measuring using health-related quality measures that are self-reported and language appropriate. However, most of the self-reported measures were devised in Europe and therefore not considered contextually appropriate in other settings, more so in Africa. Objectives: Our study aimed to produce a Swahili version by translating and adapting the stroke-specific quality of life (SSQOL) scale among people with stroke in Kenya. Method: We used a questionnaire translation and cross-cultural adaptation. The pre-validation sample of 36 adult participants was drawn from 40 registered people with stroke, from the Stroke Association of Kenya (SAoK). Quantitative data were collected using both English and Swahili versions of the SSQOL scale. The mean, standard deviation (s.d.) and overall scores were calculated and are presented in tables. Results: The back translation revealed a few inconsistencies. Minor semantic and equivalence alterations were done in the vision, mood, self-care, upper extremity function and mobility domains by the expert review committee. Respondents indicated that all questions were well-understood and captured. The stroke onset mean age was 53.69 years and the standard deviation was 14.05. Conclusion: The translated version of the Swahili SSQOL questionnaire is comprehensible and well-adapted to the Swahili-speaking population. Clinical implication: The SSQOL has the potential to be a useful outcome measure for use in Swahili-speaking patients with stroke

Accuracy of magnetic resonance imaging in detecting lumbo-sacral nerve root compromise: A systematic literature review

Background: MRI is considered to be the diagnostic tool of choice in diagnosing nerve root compromise among patients presenting with clinical suspicion of lumbo-sacral radiculopathy. There exists controversy among researchers and clinicians regarding the diagnostic utility and accuracy of MRI in detecting nerve root compromise and radiculopathy. This review evaluated 4 primary diagnostic accuracy studies that specifically assessed the accuracy of MRI in detecting nerve root compromise, as established in the current literature. Methods: Eight electronic data bases were searched for relevant articles from inception until January 2014. All primary diagnostic studies which investigated the accuracy of MRI in diagnosing nerve root compromise among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the 'Quality Assessment of Diagnostic tests Accuracy Studies' criteria. Results: Four studies qualified for inclusion in this review. The sensitivity of MRI in detecting lumbar nerve root compromise was very low at 0.25 (95 % CI) while the specificity was relatively high at 0.92 (95 % CI). Conclusions: There is lack of sufficient high quality scientific evidence in support or against the use of MRI in diagnosing nerve root compression and radiculopathy. Therefore, clinicians should always correlate the findings of MRI with the patients' medical history and clinical presentation in clinical decision making.IS

Collaborative capacity development to complement stroke rehabilitation in Africa

This scholarly book focuses on stroke in Africa. Stroke is a leading cause of disability among adults of all ages, contributing significantly to health care costs related to long term implications, particularly if rehabilitation is sub-optimal. Given the burden of stroke in Africa, there is a need for a book that focuses on functioning African stroke survivors and the implications for rehabilitation within the African context. In addition, there is a need to progress with contextualised, person-centred, evidence-based guidance for the rehabilitation of people with stroke in Africa, thereby enabling them to lead socially and economically meaningful lives. The research incorporated in the book used a range of primary and secondary methodological approaches (scoping reviews, systematic reviews, meta-analyses, descriptive studies, surveys, health economics, and clinical practice guideline methodology) to shed new insights into African-centred issues and strategies to optimise function post-stroke

Correlation of the self-reported Leeds assessment of neuropathic symptoms and signs score, clinical neurological examination and MR imaging in patients with lumbo-sacral radiculopathy

CITATION: Tawa, N., et al. 2019. Correlation of the self-reported Leeds assessment of neuropathic symptoms and signs score, clinical neurological examination and MR imaging in patients with lumbo-sacral radiculopathy. BMC Neurology, 19:107, doi:10.1186/s12883-019-1333-3.The original publication is available at https://bmcneurol.biomedcentral.comBackground: Lumbo-sacral radiculopathy (LSR) is a common musculoskeletal disorder for which patients seek medical care and referrals for advanced imaging. However, accurate diagnosis remains challenging. Neuropathic pain screening questionnaires, clinical neurological examination and magnetic resonance imaging (MRI) are used in the initial diagnosis. The utility of these tools in diagnosing LSR varies and their correlation has not been reported. Methods: A cross-sectional, multicentre, blinded design was used in six physiotherapy departments in Kenya. Each participant was blindly examined by three independent clinicians using the Self-Reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) score, clinical neurological examination (CNE) and MRI. Spearman’s rank coefficient (r) was used to examine the correlation between the three tests. Linear regression and odds ratios were used to establish correlations between socio-demographic, clinical and diagnostic parameters. The diagnostic accuracy of individual or combined sets of CNE tests in diagnosing LSR, with reference to MRI, was determined using Receiver Operating Characteristics (ROC) curves. Results: We enrolled 102 participants (44 males, 58 females; mean age: 44.7 years). Results indicated a significant positive correlation (r = 0.36, P = 0.01) between S-LANSS, CNE and MRI among patients with low back and radiating leg symptoms. Positive agreement existed between combined neuro-conduction tests (sensory, motor and reflex) and neuro-dynamic tests (NDT). The NDT component of CNE (Straight Leg Raise Test [SLRT] and Femoral Nerve Stretch Test [FNST]) was significantly associated (P = 0.05) with MRI: patients who had positive NDT results had higher odds (8.3) for positive nerve root compromise on MRI versus those who had negative NDT results. Conclusion: This was the first study to investigate the correlation between S-LANSS, CNE and MRI in patients presenting with low back and radiating leg symptoms. Results indicated a significant positive correlation. The strongest correlations to MRI findings of LSR were firstly, NDT (SLRT and FNST); secondly, the S-LANSS score; and thirdly, the CNE components of motor power and deep tendon reflex. The clinical implication is that clinicians can confidently use the S-LANSS score and CNE to diagnose and make therapeutic decisions in LSR, when MRI is medically contra-indicated, unaffordable or unavailable.https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-019-1333-3Publisher's versio