Tailored Yoga Intervention for Postlumbar Spine Surgical Pain Management: A Feasibility Study.

Introduction: Severe pain, anxiety, and high opioid use are common following lumbar spine surgery (LSS). Yoga helps to reduce pain and anxiety, but it has not been considered for postsurgical care. The authors developed and tested the feasibility of a tailored yoga program designed for individuals undergoing LSS and explored clinical feasibility of yoga intervention on measures of pain, function, psychological status, and opioid use. Methods: Individuals scheduled for LSS were randomized into yoga versus control groups presurgery. Participants in the yoga group received tailored yoga sessions plus usual care, whereas participants in the control group received usual care only during the hospital stay post-LSS. In-person daily yoga sessions were individually presented and performed in the participant's hospital room. Feasibility was assessed by recruitment and retention rates, rate of yoga session completion, tolerance to yoga intervention, and ability to carry out planned assessment. Exploratory clinical outcomes included pain, psychological measures, Timed-Up-and-Go test, gait distance, and opioid use, during the hospital stay post-LSS. Results: Forty-one participants were enrolled, of which 30 completed. There were no dropouts. Planned assessments were completed within 45 min, suggesting no excessive burden on participants. Baseline variables were similar across both groups. The majority of participants participated in yoga intervention on the day of surgery or one day after surgery with acceptance rate of 100%. Participants showed good tolerance to yoga intervention on 0-4 tolerance scale and by their reports of exploratory clinical outcomes. Conclusion: This study indicates feasibility for a modified yoga program for postoperative care following LSS due to participant tolerance and retention. The results provide preliminary framework for future confirmatory studies that can assess the potential benefits of yoga in reducing pain, catastrophizing behavior, and opioid use and improving function. A modified yoga program focusing on diaphragmatic breathing, relaxation, and core isometric contraction exercises can be an important adjunct intervention for patients undergoing LSS. CTR Number: This trial was registered in UMIN CTR (https://rctportal.niph.go.jp/en/) with registration number: UMIN000032595.

Sleep quality in individuals with chronic low back pain and central sensitization.

BACKGROUND AND PURPOSE: Sleep problems are common in individuals with chronic low back pain (CLBP). Central sensitization (CS) is present in a subgroup of individuals with CLBP. However, our knowledge about whether sleep quality varies between the subgroups of CLBP is limited. Therefore, we sought to examine whether the subgroup of CLBP with CS has poorer sleep quality than the subgroup without CS. METHODS: 2011 Fibromyalgia Survey (2011 FM survey) was used as a surrogate measure of CS to divide the CLBP participants into two subgroups: CLBP with CS and CLBP without CS. We also created a CS index comprising a set of quantitative sensory testing measures (i.e., pressure pain thresholds, conditioned pain modulation) to evaluate pain sensitivity. Sleep quality was assessed with Pittsburgh Sleep Quality Index (PSQI). Group differences about PSQI and CS index and associations between sleep quality and CS across the groups were analyzed. RESULTS: We included 60 participants with CLBP and 23 healthy controls (HCs). Overall, 80% of the participants with CLBP presented with poor sleep quality. Participants with CLBP with CS showed significantly higher PSQI scores (poorer sleep) than participants with CLBP without CS and HCs (p < 0.05). Both the 2011 FM survey and CS index were significantly correlated with sleep quality (r = 0.5870, p < 0.001 and r = -0.264, p = 0.04). Logistic regression models revealed that the FM status (odds ratio (OR) = 6.00, p = 0.02 [95% confidence interval: 1.31-42.1]), but not the CS index (OR = 1.11, p = 0.79 [95% CI: 0.48-2.71]) was associated with PSQI. After adjusting covariates, the results remained similar but became non-significant for the FM status. DISCUSSION: We found that sleep problems were more common and severe in those who exhibited signs of CS. Thus, clinicians may consider using 2011 FM survey to identify those with CS and co-existing sleep problems.

Protocol for Testing Yoga to Reduce Post-Lumbar Spine Surgery Pain: A Methodology Article.

Currently, acute postoperative pain during hospitalization is primarily managed by medications, and patients must adhere to restrictive postoperative precautions for 3 months following lumbar spine surgeries. Yoga can be an alternative approach to assist in acute and subacute postoperative pain management, anxiety, and return to function. The purpose of the present work was to develop and test the feasibility and explore the effectiveness of a tailored yoga program, delivered in-person during the hospital stay and electronically after hospital discharge, as a potential new avenue for postoperative care. This pilot study will use a crossover randomized controlled design. Individuals aged between 40 and 80 years who are scheduled for lumbar laminectomy and/or fusion, and who have not practiced regular yoga within the past 6 months at the time of enrollment, will be recruited and randomized to either a tailored yoga program (intervention group) or usual care (control group) during the hospital stay (phase one). Bearing in mind postoperative precautions, all subjects will be instructed to perform a home-based tailored yoga program delivered electronically via YouTube links for 8 weeks post-hospital discharge (phase two). The primary outcome measures assessing feasibility are adherence/compliance. Secondary outcome measures include pain, anxiety, function, sleep, perceived stress, and pain-catastrophizing behavior. Length of hospital stay and pain medication use, gait distance, and overall physical activity during hospitalization will also be collected. Finally, a qualitative interview will be obtained after completion of the hospital and home-based programs. This study will determine the feasibility of a tailored yoga program for acute and subacute postoperative lumbar spine surgery pain, anxiety, and functional outcomes.

The effect of age and gender on acute postoperative pain and function following lumbar spine surgeries.

BACKGROUND AND PURPOSE: Understanding the factors contributing to the variability in postoperative pain and function following lumbar spine surgeries (LSS) is necessary to plan inpatient rehabilitation and optimize surgical outcomes. In particular, variability due to age and gender has not been studied. This study's aim was to evaluate the variability in postoperative pain and function, during hospital stay, due to age and gender following LSS. METHODS: We conducted a retrospective analysis of 585 patients who underwent LSS during their hospital stay. Univariate ANCOVA was performed to study the differences in postoperative pain, and multivariate ANCOVA was performed to study the differences in postoperative function (gait distance, independency combined score, and balance combined score) between age groups (older adults [≥65 years of age] vs. younger adults) and gender. RESULTS: Younger patients reported statistically, but not clinically, significant higher postoperative pain than older patients (ß = 0.652 [95% CI (0.382-0.986)], p < 0.001), and males reported statistically, but not clinically, significant lower postoperative pain than female patients (ß = -0.583 [95% CI (-0.825 to -0.252)], p < 0.001) with adjustment of covariates. Male patients walked significantly longer distance than female patients (ß = 0.272 [95% CI (0.112-0.432)], p = 0.001) with adjustment of covariates. However, these were clinically insignificant. With adjustment of preoperative diagnosis, type of surgery, severity of illness, and prior level of function, there was no statistically significant difference between age groups in walking distance, and between age and gender groups in independency combined score and balance combined scores. DISCUSSION: Following LSS, the difference in postoperative pain between age groups and gender are statistically but not clinically significant, suggesting patients require similar effective postoperative pain management regardless of age and gender. The apparent difference in age and gender in postoperative functional outcomes could be due to other factors.

Correlation Between Central Sensitization and Remote Muscle Performance in Individuals With Chronic Low Back Pain.

OBJECTIVE: The purpose of this study was to examine associations between the degree of central sensitization (CS) and remote muscle performance in people with chronic low back pain (CLBP). METHODS: The 2011 fibromyalgia (FM) criteria and severity scales (2011 FM survey) were used as a surrogate measure of CS to divide the participants into 2 groups: FM-positive CLBP and FM-negative CLBP. Measures related to central sensitization included the 2011 FM survey and pressure pain threshold of the thumbnail. Measures related to muscle performance included neck flexor muscle strength and endurance and plantar flexor muscle strength. Between-groups and correlation analyses were performed. RESULTS: Sixty people with CLBP were enrolled (30 FM-positive, 30 FM-negative). There was no significant difference between the subgroups in age, sex, or pain duration (P > .05). The FM-positive CLBP group showed poorer neck flexor muscle endurance (P = .01) and plantar flexor muscle strength (P = .002) than the FM-negative CLBP group, whereas neck flexor muscle strength was not different between the groups (P = .175). Scores for FM and values for pressure pain thresholds of the thumbnail were associated with neck flexor muscle strength (respectively, r = -0.320, P = .013, and r = 0.467, P < .001), endurance (r = -0.242, P < .001, and r = 0.335, P = .009), and plantar flexor muscle strength (r = -0.469, P < .001, and r = 0.500, P < .001). CONCLUSION: We found associations between the degree of CS and remote muscle strength and endurance, suggesting that poor remote muscle performance is possibly a clinical sign of CS in people with CLBP.

Inertial sensors identified asymmetries in shank angular velocity at different gait speeds in individuals with anterior cruciate ligament reconstruction.

BACKGROUND: Inertial sensors can detect between-limb asymmetries in shank angular velocity (SAV) during loading response of walking in individuals with ACL reconstruction (ACLR), which may be indicative of abnormal knee joint loading. However, it is unknown whether these SAV asymmetries would exist up to 6 months post-ACLR and how they differ from SAV asymmetries in uninjured healthy subjects. RESEARCH QUESTION: To investigate whether patients with ACLR show significant and meaningful between-limb SAV asymmetries during walking and walking fast at 4 and 6 months post-surgery and to determine whether limb asymmetries are related across gait tasks and time. METHODS: Fifteen individuals with ACLR participated in this prospective study. Testing occurred in clinical settings. Participants were instructed to walk and walk fast while wearing one inertial sensor on each shank. The average of sagittal plane SAV peaks during loading response of gait was calculated bilaterally. The smallest meaningful between-limb difference for SAV was calculated from uninjured healthy subjects (n = 16) to define the limit of meaningful SAV asymmetries in patients with ACLR. RESULTS: At 4 and 6 months post-ACLR, the involved limb had significantly smaller peak SAV during walking (P < .01, d = 0.69-0.85) and walking fast (P < .005, d = 1.03-1.07) compared to the uninvolved limb. A significant main effect of gait task on SAV asymmetries was found (P = .006, ηp2 = 0.451). Further, patients with ACLR exhibited meaningful SAV asymmetries at both time points for both gait speeds. Limb SAV asymmetries correlated between gait tasks and across time (r = 0.760-0.860, P < .001). SIGNIFICANCE: Individuals with ACLR presented with significant and meaningful SAV asymmetries during walking and walking fast at 4 and 6 months post-surgery. Greater limb SAV asymmetries persisted across gait tasks and time, with greater asymmetry was observed at a faster walking speed. Thus, inertial sensors are feasible to be used in clinical settings to identify SAV asymmetry during gait post-ACLR.

Association between Opioid Dose, Acute Post-operative Pain and Walking Distance Following Lumbar Spine Surgery.

WHAT IS KNOWN AND OBJECTIVE: The opioid doses on post-operative day 1 (POD1) is a major predictor of recovery in patients following lumbar spine surgery (LSS). However, the opioid doses vary widely in clinical practice. Thus, the objective of this study was to explore the associations between opioid doses on POD1, pain and function during a hospital stay in patients following LSS. METHODS: This study used medical records of patients who underwent LSS between January 2007 and March 2018. The patients were divided into three groups (high, medium and low dose) according to the amount of opioid (oral morphine equivalents; OME) taken on POD1. A propensity score matching across the three groups was performed to account for main confounding factors related to the opioid dose, pain intensity and gait distance, which identified 114 matched patients in each group. The difference of pain intensity and gait distance between the groups on POD1 was analysed. RESULTS: The OME in each group on POD1 was 168.75 ± 69.50 mg (high), 65.92 ± 13.28 mg (medium) and 16.90 ± 9.80 mg (low) (P < .0001). Pain intensity on the postoperative day 2 (POD2) and 3 (POD3) was not different between the groups (P > .05). Gait distance on POD2 and POD3 was different between the groups but did not reach the adjusted statistically significant level of 0.017: high (170.3 ± 152.77 feet) versus medium (247.57 ± 216.65 feet) dose on POD2 (P = .04); high (179.31 ± 135.722 feet) versus low (230.94 ± 145.74 feet) dose on POD3 (P = .03); and medium (196.98 ± 159.42 feet) versus low (261.00 ± 161.03 feet) dose on POD3 (P = .09). WHAT IS NEW AND CONCLUSION: The findings indicated that high dose opioids on POD1 did not translate into better outcomes of pain and gait in patients following LSS. In fact, patients in medium and low dose groups walked a greater distance on POD2 and POD3. Use of a functional outcome such as gait should be considered to optimize opioid dose effects.

Physical and Physiological Effects of Yoga for an Underserved Population with Chronic Low Back Pain.

BACKGROUND: Yoga has been shown useful in reducing chronic low back pain (CLBP) through largely unknown mechanisms. The aim of this pilot study is to investigate the feasibility of providing yoga intervention to a predominantly underserved population and explore the potential mechanisms underlying yoga intervention in improving CLBP pain. METHODS: The quasi-experimental within-subject wait-listed crossover design targeted the recruitment of low-income participants who received twice-weekly group yoga for 12 weeks, following 6-12 weeks of no intervention. Outcome measures were taken at baseline, preintervention (6-12 weeks following baseline), and then postintervention. Outcome measures included pain, disability, core strength, flexibility, and plasma tumor necrosis factor (TNF)-α protein levels. Outcomes measures were analyzed by one-way ANOVA and paired one-tailed t-tests. RESULTS: Eight patients completed the intervention. Significant improvements in pain scores measured over time were supported by the significant improvement in pre- and post-yoga session pain scores. Significant improvements were also seen in the Oswestry Disability Questionnaire scores, spinal and hip flexor flexibility, and strength of core muscles following yoga. Six participants saw a 28.6%-100% reduction of TNF-α plasma protein levels after yoga, while one showed an 82.4% increase. Two participants had no detectable levels to begin with. Brain imaging analysis shows interesting increases in N-acetylaspartate in the dorsolateral prefrontal cortex and thalamus. CONCLUSION: Yoga appears effective in reducing pain and disability in a low-income CLBP population and in part works by increasing flexibility and core strength. Changes in TNF-α protein levels should be further investigated for its influence on pain pathways.

A Subgroup of Chronic Low Back Pain Patients With Central Sensitization.

BACKGROUND: Our knowledge of central sensitization (CS) in chronic low back pain (CLBP) is limited. 2011 fibromyalgia criteria and severity scales (2011 FM survey) have been used to determine FM positive as a surrogate of CS. The major features of CS including widespread hyperalgesia and dysfunction of the descending inhibitory pathways can be identified by pressure pain threshold (PPT) and conditioned pain modulation (CPM) tests. The purpose of the study was to examine neurophysiological characteristics and psychosocial symptoms in a subgroup of FM-positive CLBP compared with FM-negative CLBP patients. METHODS: A total of 46 participants with CLBP and 22 pain-free controls completed outcome measures of the 2011 FM survey, PPT and CPM tests, and psychosocial questionnaires. Differences between FM-positive and FM-negative CLBP participants on these measures and correlations were analyzed. RESULTS: The 2011 FM survey identified 22 (48%) participants with CLBP as FM positive. FM-positive CLBP participants showed lower PPT values of the thumbnail (P=0.011) and lower back (P=0.003), lower CPM values of the thumbnail (P=0.002), and more severe pain catastrophizing, anxiety, and depression symptoms (P<0.05) than FM-negative CLBP participants. The 2011 FM scores were significantly correlated with the PPT and CPM values of the thumbnail and with psychosocial symptoms (P<0.001). DISCUSSION: Our findings suggest a subgroup of CLBP patients exhibiting with signs and symptoms of CS. Associations between subjective and objective CS measures indicate that the 2011 FM survey can be utilized to identify the presence of CS in CLBP in clinical practice.

Using Electronic Health Record Activity to Represent Interdisciplinary Care Teams and Examining their Contribution to Hospital Length of Stay.

Modeling variance in patient outcomes using medical claims and other forms of aggregated administrative data may ignore significant contributions associated with providers who are not recorded in billing transactions. We examined the association between interdisciplinary provider factors and length of stay (LOS) for 1,099 lumbar spine surgery patients. Interdisciplinary provider "dose" (number of providers/case), "workload" (care of other patients), and "activity" factors were defined and generated. Hierarchical Regression models were used to test the impact of these provider factors controlling for the effect of socio-demographic and clinical factors. Interdisciplinary provider factors explained 12% of additional variance in LOS. EHR-based interdisciplinary care team representations hold promise in contributing to our understanding of health care delivery and quality. Keywords: interdisciplinary care, nursing documentation, workload, length of stay, electronic health records (EHR).

Lumbar Spine Surgeries and Medication Usage During Hospital Stay: One-Center Perspective.

Background: Pain after spine surgery is usually managed with opioid and nonopioids. The rate of lumbar spine surgeries (LSS) is rising, but current practices on LSS are not known. A current trend in LSS and medication usage by age group is needed to gain a better understanding of how LSS and its pain management vary by age. Objective: The aim of this study was to report current practices of LSS of discectomy, laminectomy, and fusion in patients aged 18 and older and to gain an understanding of medication use for management of LSS. Methods: This retrospective study analyzed data of the University of Kansas Medical Center from 2007 to 2014 of patients (>18 years of age) undergoing laminectomy, discectomy, and fusion. Results: A total of 19 463 patients underwent LSS between 2007 and 2014 at Kansas University hospital. For the purpose of this study, 3115 patients' medical records were observed. A 50% increase in LSS between 2007 and 2014 was noted. Specifically, more than 2-fold increase in LSS was observed in patients aged 65 years and older. Among those aged 65 years and older, laminectomy was the most commonly performed surgery (69.6%) while discectomy was the most common surgery performed among those aged 18 to 34 (82.9%) and those aged 35 to 44 (72%). The medication use also increased with a highest usage in opioids alone (55%), followed by opioids combined with other analgesics (42.7%), regardless of lumbar surgery type or age. Conclusion: The information of increase in both LSS and the medication usage over the 7 years can be used to gain a better understanding of quality, expenditure, and outcomes following LSS. This knowledge may help health care providers plan patient care and rehabilitation services for older adults, as the trajectory of lumbar spine surgery is likely to rise with growing prevalence of older adults. The information regarding increased opioid utilization may also help clinicians to refine opioid usage and consider alternative approaches to manage acute postoperative pain, in light of the current concerns related to overutilization of opioids.

Investigating and predicting early lumbar spine surgery outcomes.

OBJECTIVE: To examine short-term changes in patients' clinical status following lumbar spine surgery (LSS) and to explore presurgical variables that predict surgical outcomes. METHODS: Prospective cohort study. A total of 46 patients underwent LSS. Patients completed the following questionnaires 1 week before LSS and 2 weeks after discharge from the hospital: back and leg visual pain analogue scale, Ronald Morris questionnaire (RMQ), Modified Somatic Perception questionnaire (MSPQ), SF-36, Fear-Avoidance Beliefs Questionnaire, Beck's Depression Inventory, EuroQol questionnaire, and patient-perception of improvement. Regression models were constructed to examine predictors of pain, function, quality of life, and patient-perception of improvement at 2 weeks postsurgery. RESULTS: Patients demonstrated significant improvement in back and leg pain and function. MSPQ and symptom duration were significant predictors of back pain, while type of diagnosis and use of opioids were significant predictors of leg pain. Preoperative MSPQ and RMQ were significant predictors of postoperative RMQ. MSPQ, gender, and back pain were significant predictors of quality of life. Back pain, leg pain, depression, smoking, and worker's compensation were significantly associated with patient-perception of improvement. CONCLUSIONS: This preliminary study could be viewed as a directory to identify potential risk factors for unfavorable outcomes at early stages following LSS.

Structural equation model analysis of the length-of-hospital stay after lumbar spine surgery.

BACKGROUND CONTEXT: Length-of-hospital stay (LOS) after lumbar spine surgery (LSS) can be affected by many factors. However, few studies have evaluated predictors of LOS, and all have used limited number of variables as predictors. PURPOSE: The purpose of the study was to identify presurgical, surgical, and postsurgical predictors of LOS after LSS. STUDY DESIGN/SETTING: Retrospective review of consecutive patients who had LSS at the University of Kansas Hospital from October 2008 to April, 2012. PATIENT SAMPLE: Five hundred ninety-three patients underwent LSS consisting of laminotomy, laminectomy, or arthrodesis. DEPENDENT VARIABLE: LOS. Multiple presurgical, surgical, and postsurgical variables were extracted from the patients' medical records and considered as possible predictors (independent variables) of LOS. METHODS: Potential predictors that were significantly correlated with LOS were used as indicators to construct three latent factors presurgical, surgical, and postsurgical, which were in turn used to predict LOS in a structural equation model. RESULTS: The average LOS was 4.01±2.73 days. The presurgical factor was indicated by age (61.97±14.49 years), previous level of function (60.5% were totally independent), previous hemoglobin level (13.70±1.36 mg/dL), and use of assistive devices (60% were assistive device users). The surgical factor was indicated by severity of illness (50.2% had minor disease severity), presence of complications (1.9%), and stay in an intensive care unit (4.0%). The postsurgical factor was indicated by postsurgical walking distance (166.43±175.75 ft), level of assistance during walking (5.18±0.81 out of 7 points), balance scores (6.18±1.82 out of 10 points), and bed mobility and transfer dependency scores (9.81±1.99 out of 14 points). These three latent factors explained 47% of variation in LOS. CONCLUSIONS: Postsurgical factors predicted the highest variation in LOS in comparison with presurgical and surgical factors and should be taken into consideration for discharge planning. Postsurgical factors are related to the patient's function, modifiable with rehabilitation, and can be improved to shorten LOS. Inclusion of more reliable and standardized presurgical variables could improve the predictability of the model.

The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy.

UNLABELLED: Although exercise can significantly reduce the prevalence and severity of diabetic complications, no studies have evaluated the impact of exercise on nerve function in people with diagnosed diabetic peripheral neuropathy (DPN). The purpose of this pilot study was to examine feasibility and effectiveness of a supervised, moderately intense aerobic and resistance exercise program in people with DPN. We hypothesized that the exercise intervention can improve neuropathic symptoms, nerve function, and cutaneous innervation. METHODS: A pre-test post-test design was used to assess change in outcome measures following participation in a 10-week aerobic and strengthening exercise program. Seventeen subjects with diagnosed DPN (8 males/9 females; age 58.4±5.98; duration of diabetes 12.4±12.2 years) completed the study. Outcome measures included pain measures (visual analog scale), Michigan Neuropathy Screening Instrument (MNSI) questionnaire of neuropathic symptoms, nerve function measures, and intraepidermal nerve fiber (IENF) density and branching in distal and proximal lower extremity skin biopsies. RESULTS: Significant reductions in pain (-18.1±35.5 mm on a 100 mm scale, P=.05), neuropathic symptoms (-1.24±1.8 on MNSI, P=.01), and increased intraepidermal nerve fiber branching (+0.11±0.15 branch nodes/fiber, P=.008) from a proximal skin biopsy were noted following the intervention. CONCLUSIONS: This is the first study to describe improvements in neuropathic and cutaneous nerve fiber branching following supervised exercise in people with diabetic peripheral neuropathy. These findings are particularly promising given the short duration of the intervention, but need to be validated by comparison with a control group in future studies.

Acidic saline-induced primary and secondary mechanical hyperalgesia in mice.

UNLABELLED: Most of our knowledge about chronic musculoskeletal pain is based on cutaneous pain models. To test the hypothesis that animals develop chronic muscular hyperalgesia following intramuscular acidic saline injections, primary hyperalgesia within the gastrocnemius muscle was analyzed compared to secondary cutaneous hyperalgesia in the hind paw that develops following intramuscular acid saline injection. Two acidic saline (pH 4) injections were administrated into the gastrocnemius of female CF-1 mice. The results indicate that mice developed a robust hypersensitivity bilaterally in primary (gastrocnemius muscle) secondary (cutaneous hind paw) sites that lasted up to 2 weeks. In addition, primary hyperalgesia correlated well with levels of Fos expression. Fos expression patterns in the spinal cord were different for primary secondary site stimulation. Hind-paw palpation stimulated ipsilateral Fos expression in the superficial spinal laminae at L4/L5 levels, bilaterally in deep laminae at L2-L5 spinal levels. In contrast, gastrocnemius compression stimulated widespread Fos expression in all regions of the ipsilateral dorsal horn within L2-L6 spinal segments. These findings indicate that acidic saline injection induces primary hyperalgesia in muscle that the patterns of Fos expression in response to primary vs secondary stimulation are strikingly different. PERSPECTIVE: This study assesses primary site muscular pain, which is the main complaint of people with musculoskeletal conditions, and identifies spinal patterns activated by noxious mechanical stimuli to the gastrocnemius. This study demonstrates approaches to test nociception arising from muscle aids in our understanding of spinal processing of primary secondary site hyperalgesia.