Consensus on a standardised treatment pathway algorithm for lumbar spinal stenosis: an international Delphi study.

BACKGROUND: Lumbar spinal stenosis (LSS) is a common degenerative spinal condition in older adults associated with disability, diminished quality of life, and substantial healthcare costs. Individual symptoms and needs vary. With sparse and sometimes inconsistent evidence to guide clinical decision-making, variable clinical care may lead to unsatisfactory patient outcomes and inefficient use of healthcare resources. METHODS: A three-phase modified Delphi study comprising four consensus rounds was conducted on behalf of the International Taskforce for the Diagnosis and Management of LSS to develop a treatment algorithm based on multi-professional international expert consensus. Participants with expertise in the assessment and management of people with LSS were invited using an international distribution process used for two previous Delphi studies led by the Taskforce. Separate treatment pathways for patients with different symptom types and severity were developed and incorporated into a proposed treatment algorithm through consensus rounds 1 to 3. Agreement with the proposed algorithm was evaluated in the final consensus round. RESULTS: The final algorithm combines stratified and stepped approaches. When indicated, immediate investigation and surgery is advocated. Otherwise, a stepped approach is suggested when self-directed care is unsatisfactory. This starts with tailored rehabilitation, then more complex multidisciplinary care, investigations and surgery options if needed. Treatment options in each step depend on clinical phenotype and symptom severity. Treatment response guides pathway entrance and exit points. Of 397 study participants, 86% rated their agreement ≥ 4 for the proposed algorithm on a 0-6 scale, of which 22% completely agreed. Only 7% disagreed. Over 70% of participants felt that the algorithm would be useful for clinicians in public healthcare (both primary care and specialist settings) and in private healthcare settings, and that a simplified version would help patients in shared decision-making. CONCLUSIONS: International and multi-professional agreement was achieved for a proposed LSS treatment algorithm developed through expert consensus. The algorithm advocates different pathway options depending on clinical indications. It is not intended as a treatment protocol and will require evaluation against current care for clinical and cost-effectiveness. It may, however, serve as a clinical guide until evidence is sufficient to inform a fully stratified care model.

Practical assessment in patients suffering from musculoskeletal disorders.

Short review of exemplary clinical assessment methods to describe clinical evidence-based assessment for patients suffering from symptoms of musculoskeletal pain.History and physical examination are the primary evidence-based assessment instruments for pain patients. Pain scales and questionnaire might allow assessment of different aspects of pain in order to perform an individualized therapy for pain patients.

Musculoskeletal, Neurologic, and Cardiopulmonary Aspects of Physical Rehabilitation in Patients with Chronic Graft-versus-Host Disease.

Chronic graft-versus-host disease (cGVHD) has the potential to cause significant morbidity and mortality in people who undergo allogeneic hematopoietic stem cell transplantation. Management of complications due to cGVHD can be challenging because of multiorgan involvement and variable presentation of the disease. This paper outlines the diagnosis and management of musculoskeletal, neurologic, and cardiopulmonary manifestations of cGVHD that have the potential to cause profound functional impairment and that may significantly impact quality of life and lifespan. Expert evaluation by a physical medicine and rehabilitation physician and multidisciplinary team may be beneficial in the treatment of the disease sequelae, and examples of specific rehabilitation interventions are described.

Patient perception of pain versus observed pain behavior during a standardized electrodiagnostic test.

INTRODUCTION: Clinicians often assume that observations of pain behavior are adequate for assessment of patient pain perception during procedures. This has not been tested during a standardized electrodiagnostic experience. METHODS: During a prospective trial including extensive, standardized electrodiagnostic testing on persons with lumbar stenosis, vascular claudication, and asymptomatic volunteers, the subjects and an observer rated levels of pain. RESULTS: In 60 subjects, observers significantly under-rated pain (Visual Analog Scale 3.17 ± 2.23 vs. 4.38 ± 2.01, t = -4.577, df = 59, P < 0.001). Perceived pain during testing related to bodily pain as measured by the visual analog, McGill, Pain Disability, and Quebec scales, but not age, duration of symptoms, Tampa kinesiphobia, Center for Epidemiological Studies Depression scale, or SF-36 health quality of life. CONCLUSIONS: Persons with worse pain syndromes may perceive more pain during testing than others. Clinicians and researchers should understand that patients may have more pain than they recognize.

Promoting medical students' reflection on competencies to advance a global health equities curriculum.

BACKGROUND: The move to frame medical education in terms of competencies - the extent to which trainees "can do" a professional responsibility - is congruent with calls for accountability in medical education. However, the focus on competencies might be a poor fit with curricula intended to prepare students for responsibilities not emphasized in traditional medical education. This study examines an innovative approach to the use of potential competency expectations related to advancing global health equity to promote students' reflections and to inform curriculum development. METHODS: In 2012, 32 medical students were admitted into a newly developed Global Health and Disparities (GHD) Path of Excellence. The GHD program takes the form of mentored co-curricular activities built around defined competencies related to professional development and leadership skills intended to ameliorate health disparities in medically underserved settings, both domestically and globally. Students reviewed the GHD competencies from two perspectives: a) their ability to perform the identified competencies that they perceived themselves as holding as they began the GHD program and b) the extent to which they perceived that their future career would require these responsibilities. For both sets of assessments the response scale ranged from "Strongly Disagree" to "Strongly Agree." Wilcoxon's paired T-tests compared individual students' ordinal rating of their current level of ability to their perceived need for competence that they anticipated their careers would require. Statistical significance was set at p < .01. RESULTS: Students' ratings ranged from "strongly disagree" to "strongly agree" that they could perform the defined GHD-related competencies. However, on most competencies, at least 50 % of students indicated that the stated competencies were beyond their present ability level. For each competency, the results of Wilcoxon paired T-tests indicate - at statistically significant levels - that students perceive more need in their careers for GHD-program defined competencies than they currently possess. CONCLUSION: This study suggests congruence between student and program perceptions of the scope of practice required for GHD. Students report the need for enhanced skill levels in the careers they anticipate. This approach to formulating and reflecting on competencies will guide the program's design of learning experiences aligned with students' career goals.

A review of electromyography techniques of the cervical paraspinal muscles.

Electrodiagnosis for cervical radiculopathy often involves exploration of the cervical paraspinal muscles. Accurate and reproducible results require a technique with specific anatomic localization, direction of insertion, extent of insertion, scoring system for insertion, and criteria for determining abnormality. We sought to understand if a published technique met these criteria. A Medline search found 39 articles with original research and 10 review articles involving the cervical paraspinals. A library search found 19 textbooks since 2000, but 9 were not available. Only two studies were specific to the question. Neither had reproducible techniques and they contradicted each other. Studies in which the paraspinals were used for comparison or inclusion did not provide any specific technique. The review articles and textbooks typically met none of our criteria and the few that discussed technique at all provided no reproducible methods. Despite 80 years of electrodiagnostic testing, there is no useful, reproducible technique for exploring the cervical paraspinal muscles. Yet such a paraspinal mapping technique has proven invaluable in the lumbar region. For cervical electromyography to be of value, the next step is to understand the anatomy and propose a reproducible technique. Subsequent research will determine whether the neck muscles are helpful in the diagnosis of cervical radiculopathy. The absence of a valid reproducible cervical paraspinal technique impedes clinical and scientific understanding of cervical radiculopathy.

Anatomical study and proposed EMG technique for the cervical paraspinal muscles.

Paraspinal electromyography has proven to be the most sensitive component of the electrodiagnostic examination for lumbar spinal disorders. However, no standardized, anatomically validated technique has been proposed for the cervical region. This study reviewed the published textbooks on cervical paraspinal anatomy to develop a standardized electromyography technique and scoring system. A library search found 32 anatomy texts published between 2000 and 2021. Of these 11 were unique and appropriate. Most texts described the basic muscle anatomy similarly, but only one cited original research. When the spinous process is defined as the origin, the multifidus and deeper rotatores appear innervated by the posterior primary rami of single cervical roots. However, texts differ in the number of pennae, between two and five, traveling to transverse process regions below. These are crowded into a small area between the spinous processes and transverse processes. Based on this understanding, a proposed cervical paraspinal mapping technique involves skin insertions from 1 to 2 cm lateral to the C5, C7, and T2 spinous processes. The needle samples transversely and deep toward midline, contacts bone, then is withdrawn and redirected to sample medial and caudally to midline to bone, creating two scores of 0-4 at three levels, theoretically resulting in scores of 0-24. This technique must be validated by clinical research to determine the range of normal, reproducibility, and the spectrum of findings in various disorders.

Symmetry of paraspinal muscle denervation in clinical lumbar spinal stenosis: support for a hypothesis of posterior primary ramus stretching?

INTRODUCTION: Denervation of the paraspinal muscles in spinal disorders is frequently attributed to radiculopathy. Therefore, patients with lumbar spinal stenosis causing asymmetrical symptoms should have asymmetrical paraspinal denervation. METHODS: Seventy-three patients with clinical lumbar spinal stenosis, aged 55-85 years, completed a pain drawing and underwent masked electrodiagnostic testing, including bilateral paraspinal mapping and testing of 6 muscles on the most symptomatic (or randomly chosen) limb. RESULTS: With the exception of 10 subjects with unilateral thigh pain (P = 0.043), there was no relationship between side of pain and paraspinal mapping score for any subgroups (symmetrical pain, pain into 1 calf only). Among those with positive limb EMG (tested on 1 side), no relationship between side of pain and paraspinal EMG score was found. CONCLUSION: Evidence suggests that paraspinal denervation in spinal stenosis may not be due to radiculopathy, but rather due to stretch or damage to the posterior primary ramus.

The risk of hematoma following extensive electromyography of the lumbar paraspinal muscles.

INTRODUCTION: The purpose of this study is to provide a controlled trial looking at the risk of paraspinal hematoma formation following extensive paraspinal muscle electromyography. METHODS: 54 subjects ages 55-80 underwent MRI of the lumbar spine before or shortly after electromyography using the paraspinal mapping technique. A neuroradiologist, blinded to the temporal relationship between the EMG and MRI, reviewed the MRIs to look for hematomas in or around the paraspinal muscles. RESULTS: Two MRIs demonstrated definite paraspinal hematomas, while 10 were found to have possible hematomas. All hematomas were < 15 mm, and none were close to any neural structures. There was no relationship between MRI evidence of hematoma and either the timing of the EMG or the use of aspirin or other nonsteroidal anti-inflammatory drugs. CONCLUSIONS: Paraspinal electromyography can be considered safe in the general population and those taking nonsteroidal anti-inflammatory drugs.

Changes in objectively measured physical activity (performance) after epidural steroid injection for lumbar spinal stenosis.

OBJECTIVE: To examine changes in objectively measured physical activity (performance) at 1 week following epidural steroid injection for lumbar spinal stenosis. DESIGN: Prospective cohort. SETTING: University spine program. PARTICIPANTS: Individuals (N=17) who were undergoing fluoroscopically guided epidural steroid injection for symptomatic lumbar spinal stenosis (mean age ± SD, 70.1±6.7; 47% women). INTERVENTION: Fluoroscopically guided epidural injection. MAIN OUTCOME MEASURE(S): The 2 primary outcomes, measured with accelerometers, were total activity (performance) measured over 7 days and maximum continuous activity (capacity). Walking capacity was also assessed with the Self-Paced Walking Test, and subjects completed the Oswestry Disability Index, Swiss Spinal Stenosis Questionnaire, Medical Outcomes Study 36-Item Short-Form Health Survey, visual analog pain scales, and body diagrams. RESULTS: At 1 week postinjection, 58.8% of the subjects demonstrated increased total activity and 53% had increased maximum continuous activity, although neither change was statistically significant. Significant improvements were observed in a number of the self-report instruments, including the Physical Function Scale of the Swiss Spinal Stenosis Questionnaire, general health (Medical Outcomes Study 36-Item Short-Form Health Survey), role-limitation emotional (Medical Outcomes Study 36-Item Short-Form Health Survey), leg pain intensity (visual analog pain scales), and presence of leg weakness. CONCLUSIONS: While patients perceived improvements in pain and function following injection, these improvements were not reflected in significant changes in performance or capacity. Future studies will continue to find value in subjective measures of pain and quality of life. However, with modern technology, performance is no longer a subjective variable. Use of activity monitors to objectively measure performance can result in more rigorous validation of treatment effects, while simultaneously highlighting the potential need for additional postinjection rehabilitation aimed at improving performance.

Predictors of walking performance and walking capacity in people with lumbar spinal stenosis, low back pain, and asymptomatic controls.

OBJECTIVE: To examine predictors of community walking performance and walking capacity in people with lumbar spinal stenosis (LSS), compared with people with low back pain and asymptomatic control subjects. DESIGN: Retrospective analysis. SETTING: University spine program. PARTICIPANTS: Participants (N=126; 50 LSS, 44 low back pain, 32 asymptomatic control subjects) aged 55 to 80 years were studied. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Seven-day community walking distance measured by pedometer (walking performance) and a 15-minute walking test (walking capacity). All participants had lumbosacral magnetic resonance imaging, electrodiagnostic testing, and a history and physical examination, including a history of pain and neurologic symptoms, a straight leg raise test, and tests for directional symptoms, reflexes, strength, and nerve tension signs. The study questionnaire included demographic information, a history of back/leg pain, and questions about walking, exercise frequency, and pain level, as well as the standardized Quebec Back Pain Disability Scale. RESULTS: Body mass index (BMI), pain, age, and female sex predicted walking performance (r(2)=.41) and walking capacity (r(2)=.41). The diagnosis of LSS itself had no clear relationship with either walking variable. Compared with the asymptomatic group, LSS participants had significantly lower values for all walking parameters, with the exception of stride length, while there was no significant difference between the LSS and low back pain groups. CONCLUSIONS: BMI, pain, female sex, and age predict walking performance and capacity in people with LSS, those with low back pain, and asymptomatic control subjects. While pain was the strongest predictor of walking capacity, BMI was the strongest predictor of walking performance. Average pain, rather than leg pain, was predictive of walking performance and capacity. Obesity and pain are modifiable predictors of walking deficits that could be targets for future intervention studies aimed at increasing walking performance and capacity in both the low back pain and LSS populations.

Medical rehabilitation after natural disasters: why, when, and how?

Natural disasters can cause significant numbers of severe, disabling injuries, resulting in a public health emergency and requiring foreign assistance. However, since medical rehabilitation services are often poorly developed in disaster-affected regions and not highly prioritized by responding teams, physical and rehabilitation medicine (PRM) has historically been underemphasized in global disaster planning and response. Recent development of the specialties of "disaster medicine" and "disaster rehabilitation" has raised awareness of the critical importance of rehabilitation intervention during the immediate postdisaster emergency response. The World Health Organization Liaison Sub-Committee on Rehabilitation Disaster Relief of the International Society of Physical and Rehabilitation Medicine has authored this report to assess the role of emergency rehabilitation intervention after natural disasters based on current scientific evidence and subject matter expert accounts. Major disabling injury types are identified, and spinal cord injury, limb amputation, and traumatic brain injury are used as case studies to exemplify the challenges to effective management of disabling injuries after disasters. Evidence on the effectiveness of disaster rehabilitation interventions is presented. The authors then summarize the current state of disaster-related research, as well as lessons learned from PRM emergency rehabilitation response in recent disasters. Resulting recommendations for greater integration of PRM services into the immediate emergency disaster response are provided. This report aims to stimulate development of research and practice in the emerging discipline of disaster rehabilitation within organizations that provide medical rehabilitation services during the postdisaster emergency response.

Building PRM in sub-Saharan Africa.

It is estimated that about 50% of people in low- and middle- income countries who require rehabilitation do not get it. Multidisciplinary rehabilitation services led by Physical and Rehabilitation Medicine (PRM) physicians have been shown to improve functioning, independence and the quality of life of persons with reduced functioning or disability. However, there is a dearth of PRM physicians in low to middle income countries (LMICs), particularly in sub-Saharan Africa. One potential solution to this lack of specialists is the establishment of PRM training programs, which are currently lacking. The International Rehabilitation Forum (IRF) developed and implemented a fellowship program to train physicians in rehabilitation medicine and has been successful in Ghana, Ethiopia and Cameroon, all LMICs in sub-Saharan Africa. However, ongoing challenges include inadequate PRM trainers, availability of logistics and services for hands on experience, and funding. The fellowship program has a promising future and an ultimate goal of having locally trained fellows leading the program and expanding it to other LMICs. There has however been no publication of the process followed to achieve this or of a similar process undertaken anywhere in Africa. The process followed in this publication highlights the journey from engaging stakeholders to the admission of new and current fellows in training.

Cancer rehabilitation as an essential component of quality care and survivorship from an international perspective.

Background: There has recently been an emphasis on improving cancer care globally, including access to lifesaving treatment and earlier identification of disease. This will lead to more survivors stricken by impairments related to the early and late effects of cancer treatment. An unintended consequence of the noble plan to improve oncology care worldwide is demand on health care systems that may be unable to accommodate increased patient care needs for myriad reasons. As a result, those with disabilities may suffer.Methods: Literature search and input from experts in the field were used to evaluate the growing need for cancer rehabilitation and survivorship care to reduce morbidity associated with cancer treatment.Results: Many governmental and non-governmental organizations have started initiatives to improve cancer care across the continuum, and reduce the symptom burden of those living with cancer. While the start is promising, many barriers must be overcome to ensure high-quality care that would reduce cost and improve patient access, including a lack of trained rehabilitation specialists, poor coordination of efforts, and funding restrictions. Furthermore, global efforts to improve rehabilitation care often do not emphasize cancer rehabilitation, potentially leaving a gap and increasing physical and economic costs of disability. Finally, low-resource countries face unique challenges in improving cancer rehabilitation care.Conclusion: Cancer rehabilitation and survivorship care are needed to improve health care quality, as there is an expected influx of cancer patients with new global efforts to improve oncology care. To accomplish this, rehabilitation initiatives must emphasize cancer rehabilitation as a component of any program, and oncology endeavors should include a plan for the rehabilitation of cancer survivors to reduce morbidity and health care cost.Implications for RehabilitationCancer rehabilitation has the potential to reduce morbidity and health care costs associated with cancer and disability worldwideAdvocacy from international organizations regarding cancer rehabilitation is increasing, but has been disjointed and incompleteLow-resource countries in particular face several barriers to providing cancer rehabilitation and survivorship care.

Development of a language-independent functional evaluation.

UNLABELLED: Haig AJ, Jayarajan S, Maslowski E, Yamakawa KS, Tinney M, Beier KP, Juang D, Chan L, Boggess T, Loar J, Owusu-Ansah B, Kalpakjian C. Development of a language-independent functional evaluation. OBJECTIVE: To design, validate, and critique a tool for self-report of physical functioning that is independent of language and literacy. DESIGN: Software design and 2 prospective trials followed by redesign. SETTING: United States and African university hospitals. PARTICIPANTS: Outpatient and inpatient competent adults with diverse physical impairments. INTERVENTIONS: (1) Software design process leading to a Preliminary Language-Independent Functional Evaluation (Pre-L.I.F.E.); (2) patient surveys using a printed Pre-L.I.F.E. and a computer-animated Pre-L.I.F.E. tested in random order, followed by a questionnaire version of the standard Barthel Index; and (3) software redesign based on objective and qualitative experiences with Pre-L.I.F.E. MAIN OUTCOME MEASURES: Validation of the general concept that written and spoken language can be eliminated in assessment of function. Development of a refined Language-Independent Functional Evaluation (L.I.F.E.). RESULTS: A viable Pre-L.I.F.E. software was built based on design parameters of the clinical team. Fifty Americans and 51 Africans demonstrated excellent (Cronbach alpha>0.8 Americans) and good (alpha>.425 Africans) reliability. In general, the relations between Pre-L.I.F.E. and Barthel scores were excellent in the United States (interclass correlation coefficient for stair climbing, .959) but somewhat less good in Africa, with elimination functions very poorly related. The computer-animated Pre-L.I.F.E. was faster and trended to be more reliable than the printed Pre-L.I.F.E. in both the United States and Africa. Redesign meetings corrected statistical and qualitative challenges, resulting in a new tool, the L.I.F.E. CONCLUSIONS: Literacy and language translation can be eliminated from some aspects of functional assessment. The new L.I.F.E., based on solid empirical evidence and design principles, may be a practical solution to assessment of function in the global culture.

The practice of physical medicine and rehabilitation in sub-Saharan Africa and Antarctica: a white paper or a black mark?

INTRODUCTION: The medical specialty of Physical Medicine and Rehabilitation (PM&R) has had a proven impact on persons with disability and on healthcare systems. Documents such as The White Book on Physical and Rehabilitation Medicine in Europe have been important in defining the scope of practice within various regions. However in some continents the practice has not been well defined. OBJECTIVE: To explore the practice of PM&R in sub-Saharan Africa and Antarctica. METHODS: Medline searches, membership data searches, fax survey of medical schools, Internet searches and interviews with experts. RESULTS: The continents are dissimilar in terms of climate and government. However both Antarctica and sub-Saharan Africa have no PM&R training programs, no professional organisations, no specialty board requirements and no practicing physicians in the field. Since there are no known disabled children in Antarctica and adults are airlifted to world-class health care, the consequences of this deficit are minimal there. However, the 788,000,000 permanent residents of sub-Saharan Africa including approximately 78 million persons with disability are left unserved. CONCLUSIONS: Antarctica is doing fine. Africa is in a crisis. Local medical schools, hospitals doctors, and persons with disability; along with foreign volunteers, aid groups and policymakers can impact the crisis. However government--specifically national ministries of health--is ultimately responsible for the health and well-being of citizens.

Rehabilitation in Africa.

In Africa, rehabilitation services are insufficient and marred with inadequate political commitments and collaborations of stakeholders. Infrastructures and expertise for rehabilitation are scarce and poorly coordinated. Community-based rehabilitation programs are fragmented and fractured and lack working partnership with rehabilitation services in health care systems. Locally responsive policy frameworks, service delivery models, and health governance practices are prerequisites for meeting rehabilitation needs of the ever-increasing number of persons with chronic disabling conditions. Concerted global efforts are required for equitable and accessible coordinated continuum of rehabilitation care at various levels of health services and the community in most Sub-Saharan African countries.