Preoperative Neuroscience Education for Lumbar Radiculopathy · APTA CSM Anaheim . February 17-20, 2016 . Property of ISPI – not to be copied without permission . 1 . Preoperative

APTA CSM Anaheim February 17-20, 2016

Property of ISPI – not to be copied

without permission 1

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




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.




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.




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.




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.




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




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




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.




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.




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.




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


“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





• 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.




So where are we at?

In the meantime…







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?





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.


Is preoperative education important?

• 100% of patients – YES

• 99% of therapists – YES

• 92% of therapists rated preoperative

education more important than

postoperative education




• 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



Patients want to know more about (their) pain





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.


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.




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






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


education?



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?


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.


education?





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



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.





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)


LS?

The general population has a negative/ ambivalent view

of Lumbar Surgery and expecting a long recovery


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.




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.


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.




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


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




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


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…




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.




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




4. Surgical experiences and environmental

issues effects on nerve sensitivity

5. Calming the nervous system

6. Recovery after LS




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




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.




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.


• 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.





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).


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).





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).


• Physical Measurements (after

education only):

– Passive SLR increased 9 degrees

– Active trunk flexion increased 5cm






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







2015;9(11).




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.


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





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.





5. RCT - 1 Year

Louw A, Diener I, Landers MR,

Puentedura EJ. Preoperative pain


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




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




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




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

[email protected]

[email protected]

Thank you & acknowledgements…

1

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Preoperative Neuroscience Education for Lumbar Radiculopathy · APTA CSM Anaheim . February 17-20, 2016 . Property of ISPI – not to be copied without permission . 1 . Preoperative