Minimally-invasive percutaneous treatments for low back pain and leg pain: a randomized controlled study of thermal disc decompression versus mechanical percutaneous disc decompression.

BACKGROUND CONTEXT: Minimally invasive techniques have recently been developed as alternative treatments to surgical interventions, especially for small or contained herniated disc. PURPOSE: Aim of our study is to assess the efficacy of the mechanical percutaneous disc decompression (PDD) in comparison with the percutaneous radiofrequency targeted disc decompression (TDD). STUDY DESIGN: We conducted a single-center noninferiority trial in which patients who had low back pain with radicular leg pain (RLP) from a contained herniated disc were randomly assigned in a 1:1 ratio to undergo either PDD or TDD. PATIENT SAMPLE: From January 2016 to January 2017 a total of 327 patients were assessed for eligibility of whom 200 underwent randomization in the trial; 100 patients underwent the PDD and 100 underwent the TDD. OUTCOME MEASURES: The primary outcome measure was the proportion of patients who reported >50% reduction in Numeric Rating Scale (NRS) leg pain score. Secondary outcome measure included the proportion of patients who reported >30% improvement in Oswestry Disability Index (ODI) score. METHODS: Outcomes of this trial were measured with the use of patient-reported data obtained from validated questionnaires to assess the low back pain with RLP before intervention and at 6 and 12 months after interventions. MRI was performed before intervention and at 6 and 12 months after interventions. In addition to NRS and ODI scores, we collected the following data: age, gender, length of hospitalizations and return to work rate. RESULTS: When using an intention to treat analysis with those lost to follow-up and requiring a second procedure counting as failures, there were no statistically significant difference between the two treatment groups in the primary and secondary outcomes at 6 months: >50% reduction in NRS leg pain (PDD vs. TDD)=67% versus 65%; >30% ODI improvement (PDD vs. TDD)=57% versus 55%. Similarly, there were no statistically significant differences between groups in outcomes at 12 months: >50% reduction in NRS leg pain (PDD vs. TDD)=51% (95% CI 41%-60%) versus 40% (95% CI: 30%-49%); >30% ODI improvement (PDD vs. TDD)=42% (95% CI 32%-51%) versus 30% (95% CI: 21%-39%). A nonintention to treat analysis which discounted those lost to follow-up showed the only statistically significant finding was the percentage of those reporting >30% ODI at the 12 month follow-up time, favoring the PDD group: (PDD vs. TDD)=58% (95% CI 46%-69%) versus 42% (95% CI: 22%-43%). CONCLUSIONS: PDD and TDD are comparable treatments for patients presenting with low back pain with RLP unresponsive to medical therapy caused by contained disc herniations.

The recovery of reaching movement in breast cancer survivors: two different rehabilitative protocols in comparison.

BACKGROUND: Breast cancer (BC) is the most common cancer in women in the developed world. The about the sequelae of surgery, especially in case of mastectomy or modified radical mastectomy is grown. Nowadays it is important choose appropriate exercise programs to allow recovery in "quantity" but also in "quality" of the movement of the operated upper limb. AIM: The aim of this study was to verify whether specific exercises for the scapula may induce changes in fluidity of the reaching movement. DESIGN: Randomized control-trial double-blind study. SETTING: Exercise training laboratory and gait analysis laboratory. POPULATION: Sixty-three breast cancer survivors were enrolled. METHODS: Participants randomized to single rehabilitative treatment (ST), or to group rehabilitative treatment (GT). VAS, DASH and a biomechanical evaluation of upper limb were performed for each group before treatment (T0=baseline), at the end rehabilitative treatment (T1) and after three months of follow-up (T2). RESULTS: Respect within group analysis, in the ST and in the GT, for VAS an improvement along evaluation times were observed, respectively at T0 to T1 and at T0 to T2 (P<0.001) without a statistically significant difference between groups. At the same, for the DASH, the results showed the same trend without a statistically significant difference between groups. For biomechanical parameters, at T2 velocity was statistically significantly greater in the ST than in the GT (P=0.029) in contrast with the duration, that was statistically significantly greater in the GT than in the ST (P=0.010). CONCLUSIONS: Both protocols are effective in reducing pain and for functional recovery of the upper limb. The adoption of a non-intensive rehabilitation program should be implemented at least in the first year after the operation, with the adoption of specific myofascial exercises on the scapulo-thoracic joint with better results in the "qualitative" recovery of the achievement. CLINICAL REHABILITATION IMPACT: Our study emphasizes the importance of rehabilitation in BC survivors after mastectomy, even during the course of radiotherapy and chemotherapy and the adoption of specific myofascial exercises on the scapulo-thoracic joint and specific exercises of muscular stretching on the pectoral muscle. Therefore, the proposed rehabilitation protocol must be "clipped" and "integrated" according to the specific objectives for each individual patient.

Changes in Spine Alignment and Postural Balance After Breast Cancer Surgery: A Rehabilitative Point of View.

Breast cancer is the most common malignant tumor in female patients in developed countries. Recent articles indicate that one-sided mastectomy or minor breast surgery to treat breast cancer can have deleterious effects on posture and the musculoskeletal system. The purpose of this study was to investigate the alterations post-breast cancer surgery of the spine alignment associated to the balance not reported by the noninvasive instrumentation. We enrolled 30 women who had undergone treatment for breast cancer (BG) and were on a waiting-list for rehabilitation treatment and a control group of 30 healthy volunteer women (CG), matched by age and body mass index. The stabilometry was performed using a force platform (Kistler Instruments, Winterthur, Switzerland) test during quiet standing with closed-eyes (EC) and open-eyes (EO), recording the position of the center of pressure (CoP) for 51.2 sec. The stabilogram or the time plot of the two coordinates, X and Y, of the CoP was obtained, which represent anteroposterior and midlateral balance. Spinal posture was measured using the Formetric-4D rasterstereographic system (DIERS, International GmbH, Schlangenbad, Germany), and thoracic kyphotic angle, lumbar lordotic angle, and surface trunk rotation were evaluated. Sixty participants were analyzed (CG:30; BG:30). For the spine rasterstereography a statistically significant difference was shown with regard to anterior-posterior flexion of the trunk major in BG; pelvic inclination and twist of half-pelvis decreased in BG; normalized lumbosacral inversion point decreased in BG; surface rotation major in BG; and lateral deviation major in BG. Compared with the values for the stabilometry test with EO and EC, a statistically significant difference was observed, respectively, for ellipse length (mm; p = 0.04) and ellipse area (mm2; p = 0.04) with EO and in ellipse area (mm2) with EC (p = 0.05), increased in BG for both conditions. No difference was shown for CoP velocity and oscillations between the groups. Breast cancer survivors after prostheses or tissue expanders for mastectomy showed a spine's misalignment present both on the sagittal plane, both on the coronal and frontal plane, increased in BG regard to anterior-posterior flexion of the trunk, surface rotation, and lateral deviation. It is associated with greater energy expenditure for the postural balance control increased in BG with a major ellipse area in EO and EC conditions and major ellipse length in EC condition.

Therapeutic Alliance in a Single Versus Group Rehabilitative Setting After Breast Cancer Surgery: Psychological Profile and Performance Rehabilitation.

The survival rate of women after breast cancer has improved significantly worldwide. More attention should be paid to the rehabilitation intervention after surgery. Cancer rehabilitation helps breast cancer survivors maintain the highest possible physical, social, psychological, and vocational function in the limits that are imposed by the cancer and its treatments. The aim of our research was to determine the rehabilitative setting that promotes greater efficacy of the rehabilitation. A double-blind, randomized controlled trial with 45 patients enrolled was conducted. All participants were randomized into two groups: single rehabilitative training (N = 22) and group rehabilitative training (N = 23). Outcomes were assessed for each group before treatment (T0), after first 6 weeks of rehabilitative treatment (T1), and after 3 months (T2). All patients underwent the same rehabilitation treatment, but the setting differed between single and group rehabilitative training, which included four to five patients each and evaluated using Minnesota Multiphasic Personality Inventory (MMPI-2), Working Alliance Inventory Patient form (WAIP), Disabilities of Arm, Shoulder and Hand Questionnaire (DASH), and visual analog scale (VAS). Two patients dropped out in the single treatment group. In the within-group analysis at the three evaluation times, on the VAS, a significant reduction in pain was reported and maintained at the follow-up, as was observed for the DASH and WAIP scales. In the between-group analysis WAIP and Bond scale scores differed significantly in favor of the single treatment. In the group treatment, the Psychopathic Deviate, Masculine/Feminine, and Social Discomfort scales of the MMPI-2 correlated with WAIP Tot at T1. There was an association between the Correction, Hysteria, Paranoid, and Schizophrenia MMPI-2 scales and Δ VAS T0T1 in the total sample. Proposing the same rehabilitative intervention in both breast cancer groups, our results showed significant reduction in pain and good functional recovery of the upper limb, which did not depend on the setting (single or group). However, with single rehabilitation treatment, patients developed a better therapeutic alliance and experienced a more comfortable environment.

Chronic low back pain and postural rehabilitation exercise: a literature review.

Chronic low back represents one of the major causes of disability worldwide. Our narrative review has the purpose of highlighting the evidence supporting the different rehabilitative techniques described for its management. In total, 26 studies were found suitable to be included in the review (14 articles about pilates, six about McKenzie (MK), one article about Feldenkrais, three about Global Postural Rehabilitation (GPR) and two about Proprioceptive Neuromuscular Facilitation). The effect of exercise therapy was examined for each single study through changes in the main clinical outcomes (pain, disability,) quality of life (QoL) and psychological aspects and the targeted aspects of physical function (muscle strength, mobility, muscular activity and flexibility). All the techniques are effective for the study groups with respect to the control groups in reducing pain and disability and improving the QoL and maintaining benefits at follow-up; pilates, Back School, MK and Feldenkrais methods reduce pain and are more efficient than a pharmacological or instrumental approach in reducing disability and improving all psychological aspects also. GPR shows long lasting results for the last outcome. To date, it is difficult to affirm the superiority of one approach over another. Further high quality research is needed to confirm the effect of these techniques, together with the use of more appropriate evaluation measures.