Recovery trajectories over six weeks in patients selected for a high-intensity physiotherapy program after Total knee Arthroplasty: a latent class analysis.

BACKGROUND: Recovery trajectories differ between individual patients and it is hypothesizes that they can be used to predict if an individual patient is likely to recover earlier or later. Primary aim of this study was to determine if it is possible to identify recovery trajectories for physical functioning and pain during the first six weeks in patients after TKA. Secondary aim was to explore the association of these trajectories with one-year outcomes. METHODS: Prospective cohort study of 218 patients with the following measurement time points: preoperative, and at three days, two weeks, six weeks, and one year post-surgery (no missings). Outcome measures were performance-based physical functioning (Timed Up and Go [TUG]), self-reported physical functioning (Knee injury and Osteoarthritis Outcome Score-Activities of Daily Living [KOOS-ADL]), and pain (Visual Analogue Scale [VAS]). Latent Class Analysis was used to distinguish classes based on recovery trajectories over the first six weeks postoperatively. Multivariable regression analyses were used to identify associations between classes and one year outcomes. RESULTS: TUG showed three classes: "gain group" (n = 203), "moderate gain group" (n = 8) and "slow gain group" (n = 7), KOOS showed two classes: "gain group" (n = 86) and "moderate gain group" (n = 132), and VAS-pain three classes: "no/very little pain" (n = 151), "normal decrease of pain" (n = 48) and "sustained pain" (n = 19). The" low gain group" scored 3.31 [95% CI 1.52, 5.09] seconds less on the TUG than the "moderate gain group" and the KOOS "gain group" scored 11.97 [95% CI 8.62, 15.33] points better than the "moderate gain group" after one year. Patients who had an early trajectory of "sustained pain" had less chance to become free of pain at one year than those who reported "no or little pain" (odds ratio 0.11 [95% CI 0.03,0.42]. CONCLUSION: The findings of this study indicate that different recovery trajectories can be detected. These recovery trajectories can distinguish outcome after one year.

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis.

PURPOSE: To conduct a meta-analysis to describe clinical course of pain and disability in adult patients post-lumbar discectomy (PROSPERO: CRD42015020806). METHODS: Sensitive topic-based search strategy designed for individual databases was conducted. Patients (> 16 years) following first-time lumbar discectomy for sciatica/radiculopathy with no complications, investigated in inception (point of surgery) prospective cohort studies, were included. Studies including revision surgery or not published in English were excluded. Two reviewers independently searched information sources, assessed eligibility at title/abstract and full-text stages, extracted data, assessed risk of bias (modified QUIPs) and assessed GRADE. Authors were contacted to request raw data where data/variance data were missing. Meta-analyses evaluated outcomes at all available time points using the variance-weighted mean in random-effect meta-analyses. Means and 95% CIs were plotted over time for measurements reported on outcomes of leg pain, back pain and disability. RESULTS: A total of 87 studies (n = 31,034) at risk of bias (49 moderate, 38 high) were included. Clinically relevant improvements immediately following surgery (> MCID) for leg pain (0-10, mean before surgery 7.04, 50 studies, n = 14,910 participants) and disability were identified (0-100, mean before surgery 53.33, 48 studies, n = 15,037). Back pain also improved (0-10, mean before surgery 4.72, 53 studies, n = 14,877). Improvement in all outcomes was maintained (to 7 years). Meta-regression analyses to assess the relationship between outcome data and a priori potential covariates found preoperative back pain and disability predictive for outcome. CONCLUSION: Moderate-level evidence supports clinically relevant immediate improvement in leg pain and disability following lumbar discectomy with accompanying improvements in back pain. These slides can be retrieved under Electronic Supplementary Material.

Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work.

PURPOSE: Imaging (X-ray, CT and MRI) provides no health benefits for low back pain (LBP) patients and is not recommended in clinical practice guidelines. Whether imaging leads to increased costs, healthcare utilization or absence from work is unclear. Therefore, this study systematically reviews if imaging in patients with LBP leads to an increase in these outcomes. METHODS: We searched PubMed, CINAHL, EMBASE, Cochrane Library and Web of Science until October 2017 for randomized controlled trials (RCTs) and observational studies (OSs), comparing imaging versus no imaging on targeted outcomes. Data extraction and risk of bias assessment was performed independently by two reviewers. The quality of the body of evidence was determined using GRADE methodology. RESULTS: Moderate-quality evidence (1 RCT; n = 421) supports that direct costs increase for patients undergoing X-ray. Low-quality evidence (3 OSs; n = 9535) supports that early MRI may lead to an increase in costs. There is moderate-quality evidence (1 RCT, 2 OSs; n = 3897) that performing MRI or imaging (MRI or CT) is associated with an increase in healthcare utilization (e.g., future injections, surgery, medication, etc.). There is low-quality evidence (5 OSs; n = 15,493) that performing X-ray or MRI is associated with an increase in healthcare utilization. Moderate-quality evidence (2 RCTs; n = 667) showed no significant differences between X-ray or MRI groups compared with non-imaging groups on absence from work. However, low-quality evidence (2 Oss; n = 7765) did show significantly greater mean absence from work in the MRI groups in comparison with the non-imaging groups. CONCLUSIONS: Imaging in LBP may be associated with higher medical costs, increased healthcare utilization and more absence from work. These slides can be retrieved under Electronic Supplementary Material.

Correction to: Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis.

Following publication of the original article [1], the author reported that the tagging of their name had been done incorrectly during production process.

Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis.

BACKGROUND: Success rates for lumbar discectomy are estimated as 78-95% patients at 1-2 years post-surgery, supporting its effectiveness. However, ongoing pain and disability is an issue for some patients, and recurrence contributing to reoperation is reported. It is important to identify prognostic factors predicting outcome to inform decision-making for surgery and rehabilitation following surgery. The objective was to determine whether pre-operative physical factors are associated with post-operative outcomes in adult patients [≥16 years old] undergoing lumbar discectomy or microdiscectomy. METHODS: A systematic review was conducted according to a registered protocol [PROSPERO CRD42015024168]. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. radicular pain] to 31/3/2017; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥1-year follow-up, evaluating candidate physical prognostic factors [e.g. leg pain intensity and straight leg raise test], in adult patients undergoing lumbar discectomy/microdiscectomy were included. Two reviewers independently searched information sources, evaluated studies for inclusion, extracted data, and assessed risk of bias [QUIPS]. GRADE determined the overall quality of evidence. RESULTS: 1189 title and abstracts and 45 full texts were assessed, to include 6 studies; 1 low and 5 high risk of bias. Meta-analysis was not possible [risk of bias, clinical heterogeneity]. A narrative synthesis was performed. There is low level evidence that higher severity of pre-operative leg pain predicts better Core Outcome Measures Index at 12 months and better post-operative leg pain at 2 and 7 years. There is very low level evidence that a lower pre-operative EQ-5D predicts better EQ-5D at 2 years. Low level evidence supports duration of leg pain pre-operatively not being associated with outcome, and very low-quality evidence supports other factors [pre-operative ODI, duration back pain, severity back pain, ipsilateral SLR and forward bend] not being associated with outcome [range of outcome measures used]. CONCLUSION: An adequately powered low risk of bias prospective observational study is required to further investigate candidate physical prognostic factors owing to existing low/very-low level of evidence.

Natural course of pain and disability following primary lumbar discectomy: protocol for a systematic review and meta-analysis.

INTRODUCTION: Knowledge about the natural clinical course is needed to improve understanding of recovery postsurgery as outcome is poor for some patients. Knowledge of the natural clinical course of symptoms and disability will inform optimal timing and the nature of rehabilitation intervention. The objective of this study is to provide first evidence synthesis investigating the natural clinical course of disability and pain in patients aged >16 years post primary lumbar discectomy. METHODS AND ANALYSIS: A systematic review and data synthesis will be conducted. Prospective cohorts that include a well-defined inception cohort (point of surgery) of adult participants who have undergone primary lumbar discectomy/microdiscectomy will be included. Outcomes will include measurements reported on 1 or more outcomes of disability and pain, with a baseline presurgery measurement. Following development of the search strategy, 2 reviewers will independently search information sources, assess identified studies for inclusion, extract data and assess risk of bias. A third reviewer will mediate on any disagreement at each stage. The search will employ sensitive topic-based strategies designed for each database from inception to 31 January 2016. There will be no language or geographical restrictions. Risk of bias will be assessed using a modified QUality In Prognostic Studies (QUIPS) tool . Data will be extracted for time points where follow-up was at least 80%. Means and 95% CIs will be plotted over time for pain and disability. All results will be reported in the context of study quality. ETHICS AND DISSEMINATION: This review will provide the first rigorous summary of the course of pain and disability across all published prospective cohorts. The findings will inform our understanding of when to offer and how to optimise rehabilitation following surgery. Results will be published in an open access journal. The study raises no ethical issues. PROSPERO REGISTRATION NUMBER: CRD42015020806.

Physical therapy aimed at self-management versus usual care physical therapy after hip arthroscopy for femoroacetabular impingement: study protocol for a randomized controlled trial.

BACKGROUND: Femoroacetabular impingement has been recognized as a common cause of hip pain and dysfunction, especially in athletes. Femoroacetabular impingement can now be better treated by hip arthroscopy but it is unclear what postoperative rehabilitation of hip arthroscopy should look like. Several rehabilitation protocols have been described, but none presented clinical outcome data. These protocols also differ in frequency, duration and level of supervision. We developed a rehabilitation protocol with supervised physical therapy which showed good clinical results and is considered usual care in our treatment center. However, it is unknown whether, due to the relatively young age and low complication rate of hip arthroscopy patients, rehabilitation based on self-management might lead to similar results. The aims of this pilot study are (1) to determine feasibility and acceptability of the self-management intervention, (2) to obtain a preliminary estimate of the difference in effect between physical therapy aimed at self-management versus usual care physical therapy in patients who undergo hip arthroscopy for femoroacetabular impingement. METHODS/DESIGN: Thirty participants (aged 18-50 years) scheduled for hip arthroscopy will be included and randomized (after surgery) to either self-management or usual care physical therapy in this assessor-blinded randomized controlled trial. After surgery, the self-management group will perform a home-based exercise program three times a week and will receive physical therapy treatment once every 2 weeks for 14 weeks. The usual care group will receive physical therapy treatment twice a week for 14 weeks and will perform an additional home-based exercise program once a week. Assessment will occur preoperatively and at 6, 14, 26 and 52 weeks after surgery. Primary outcomes are feasibility, acceptability and preliminary effectiveness. Feasibility and acceptability will be determined by the willingness to enroll, recruitment rate, adherence to treatment, patient satisfaction, drop-out rate and adverse events. Preliminary effectiveness will be determined using the following outcomes: the International Hip Outcome Tool 33 and hip functional performance as measured with the Single Leg Squat Test 14 weeks after surgery. DISCUSSION: The results of this study will be used to help decide on the need, feasibility and acceptability of a large-scale randomized controlled trial. TRIAL REGISTRATION: This protocol was registered with the Dutch Trial Registry (NTR5168) on 8 May 2015.