Can back surgery be predicted?

800px-flickr_-_official_u-s-_navy_imagery_-_a_doctor_performs_surgeryDo you want to have back surgery? A therapist highly trained in treating back pain can tell you the odds that you will end up on a surgical table. This is a great study for patients that are debating surgical intervention. If you are already scheduled for surgery, ask your physician for a second opinion from a specially trained PT. What do you have to lose? Not all PT’s are trained the same and if your PT didn’t do a thorough assessment, go see a PT certified or Diplomaed in Mechanical Diagnosis and Therapy. I would be able to give you an honest assessment of whether therapy will be able to help you. Seek out someone trained in MDT.

MORAL OF THE STORY:

With patients that present to the clinic sub-acutely, with complaints of lower extremity pain referred from the spine, a MDT evaluation in order to assess for CP would be beneficial to predict non-response to conservative care. Patients that do not demonstrate the CP are greater than six times more likely to require surgery than patients that demonstrate CP.

 

A Critical Appraisal of Centralization and its Ability to Predict Surgical Outcome

 

P: For patients with back and leg pain

I: can patients that do not demonstrate the centralization phenomenon (CP)

C: as compared to patients that demonstrate the CP

O: be utilized to predict a surgical outcome

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with keyword terms “centralization and prognosis”. The results were limited to full text.   58 citations were found with no limit to year published.

 

Date of Search: February 2,2014

Re-evaluation date: February 9, 2014

 

Citation:

Skytte L, May S, Petersen P. Centralization: Its Prognostic Value in Patients with Referred Symptoms and Sciatica. Spine 2005;30(11):E293-E299.

 

Summary:

 

The purpose of this study is to evaluate the CP prognostic value in determining conservative or surgical treatment. This is a prospective cohort study of patients with unremitting back and leg pain, between 18 and 60 years of age. One hundred fourteen consecutive patients meeting these criteria were initially entered in the study and 54 patients were excluded based on the exclusion criteria. The exclusion criteria consisted of the following: previous lumbar spinal operation, pregnancy, serious spinal pathology, other serious pathology, Danish not the patient’s first language, symptoms present greater than 14 weeks and lack of consent.

 

Baseline data including the Nottingham Health Profile (NHP), Low Back Pain Rating Scale (LBPRS), demographic data and the Quebec Task Force (QTF) category of symptom referral. The examining therapist was blinded to the baseline data and performed a Mechanical Diagnosis and Therapy (MDT) evaluation in order to classify the subject as “centralizer” (CG), indicating that the most distal symptom was abolished and remained abolished upon returning to a neutral position, or “noncentralizer” (NCG), indicating no change during the MDT evaluation or the symptoms changed to a more distal location. Twenty-five patients were allocated to the CG and 35 patients to the NCG.

 

The treatment was the same for both the CG and NCG, consisting of “watchful waiting”. This included bed rest for those with neurological deficit and “light mobilization” for those without neurological deficit. Follow-up data was obtained at 1,2,3,6, and 12 months. Three patients from the CG and 16 from the NCG underwent surgery by the one-year follow-up. All patients were accounted for in the results.

Appraisal:

The authors satisfied six of the nine questions regarding the Quality Appraisal Checklist. A follow-up study, to establish the reliability of the results was not performed, and patients entered the study with varying acuity of symptoms. The examiner was blinded from the data collection, and the treating therapists were blinded from the examiner’s assessment.

 

Assessing the CP can predict conservative compared to surgical treatment requirements with 84% specificity and 54% specificity. The odds ratio (OR) for surgery in the NCG was calculated to be 6.17, with a 95% confidence interval (CI).

 

 

 

 

 

PHYSICAL THERAPY: The art is old, but the science is young.

By Vince Gutierrez PT, cert. MDT

 

Excerpts taken from the following article:

Thackeray A, Fritz JM, Childs JD, Brennan GP. The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial. J Orthop Sports Phys Ther. 2016;46(3):144-154

 

  1. “The cost of management for low back pain (LBP) in the United States is estimated at nearly $86 billion annually.”

Put these numbers in perspective. http://www.usdebtclock.org/state-debt-clocks/state-of-illinois-debt-clock.html. If we can come up with a better way in which to treat this epidemic, then we can decrease more than half of the debt from my home state. Performed year to year and we can theoretically reduced the debt load of each state within 100 years. I know that it sounds like it will take a long time, but so far there aren’t any better ideas. If nothing else, this number is humongous. It accounts for about 3% of all healthcare expenses.

 

  1. “Two commonly used interventions for these patients include an extension-oriented treatment approach (EOTA) and mechanical traction. The EOTA was popularized by the McKenzie examination and treatment system”

First there is a lot to say about these two sentences. One reason that MDT is so closely associated to extension based exercises is because of research articles such as this. This is not the case. The McKenzie examination and treatment system, AKA MDT, is a systematic assessment used to assess patient’s symptoms in order to classify the patient and lead to subsequent treatment. There are a lot of patients that respond to extension, but extension is not MDT. This has to be cleared up more because of a personal problem with patients being treated by a therapist that says “I use McKenzie in my treatment”, when actually the therapist has no more training than someone that has read this blog.

Next, we have to define EOTA. This basically means press-ups or cobra poses in yoga. This could also mean just standing up and leaning against a countertop with your butt pressed against the countertop for support. From this point, lean backwards as far as you can. One thing that separates MDT from EOTA is that MDT stresses mid-range (small stretch) to end-range (big stretch) with overpressure if needed.

Big point is this: MCKENZIE TREATMENT INCLUDES EXTENSION, BUT EXTENSION IS NOT MCKENZIE TREATMENT.

 

  1. “Many clinicians also report the use of traction for patients with low back and leg pain”

Some people may remember traction from old school hospital shows that has a person in a body cast with the leg suspended in the air with a weight pulling on the leg. The main thing to know is that traction is a shortened form of “DIStraction”, which means to pull apart. For low back pain, this hasn’t been used as much in the 2000’s as it has prior to this century. Previous research (performed by the same people that did this study) found that only a small percentage of people will be a good responder to traction. These people tend to have two characteristics, which will be talked about in a later point.

 

  1. “Experts generally agree that traction is most appropriate for patients with peripheral symptoms and signs of neurological compromise, for whom centralization of symptoms is a treatment goal”

“Peripheral symptoms” mean that the symptoms are in the periphery (think peripheral vision being around the outside of the eye), peripheral symptoms are around the outer limbs of the body. Centralization is moving the symptoms from the periphery to a more central location, think move the symptoms from the outer limb to the spine. [As an aside: if you see my picture, you can see that I have a two year old. She is actively pulling my arm at this time, so if I sound scatter brained, I blame her.]

 

  1. The patients that demonstrate improvement with traction in a previous study, “demonstrated at least 1 of the following: peripheralization of symptoms when moving into lumbar extension or a positive crossed straight leg raise”

Every profession has its own language. When I try to read legal documents, I fall asleep. When someone else tries to read medical documents, it can be overwhelming or intimidating. A crossed straight leg raise simply means the following: crossed (opposite leg of the leg that is having pain/numbness/tingling), straight leg (well, this one is kind of self explanatory, but keeping the leg straight), and raise (again self explanatory, but raising the leg while lying on your back).

 

  1. “This was a …longitudinal randomized trial”.

This means that the study was performed over the course of time from a start point and continued until some point in the future. Randomized means that the subjects in the study (think guinea pig) were randomly placed into one of two groups. This is like when in school and the teacher has to create groups. One of the ways to try to make the teams fair is to draw from a hat. (Another aside: In PT school there was a partner that I loved to work with because our styles totally complemented each other. She was very organized and I was [am] very much the opposite. Let’s just call her M FN Jones. Okay, she carried the team, but I can hold my own on the workload portion. Anyway, the teacher decided to pull our names from a hat on the last project after 3 years of having been allowed to work together (we partnered on almost everything we did up until that point). Needless to say, the teacher pulled our names out as the first group.) The point of that is we were randomly assigned to be in a group, which we would’ve picked in the first place…Moving on.

 

  1. Inclusion criteria is as follows: “between the ages of 18 and 60 years, presented with leg pain distal [further down the leg] to the buttock and signs of nerve root compression (positive straight leg raise [self-explanatory] or diminished dermatomes [loss of sensation at certain points in the leg], myotomes [specific weakness in the leg] or reflex…and reported moderate disability as indicated by an Oswestry Disability Index score of 20 or greater”

Here we go. Inclusion criteria means that only people that meet the specific requirements are allowed into the study. You would have to meet all of the above requirements in order to compare your self with the people in the study. The therapist that you are seeing should attempt to use research that best matches your presentation to that of what was read. For instance, it doesn’t make sense to use this article for someone that only has back pain. This article is not written for that type of patient.

Next, myotomes and dermatomes. I do a ton of patient education in the clinic. One thing to understand is that you are not special! Well, you may be special, but we are all alike in some aspects. Everyone has a spine (at least everyone that I treat, so as not offended those spineless people). The spine acts like a road map. Meaning if you have a nerve problem at L4-L5 or L5-S1 (think the lowest portion of your back), then your symptoms would travel down to the big toe or to the outer border/bottom of the foot. The reason why I use these points specifically is that about 95% of back problems come from these levels. These nerves can affect the knee jerk reflex or the foot jerk reflex (this reflex is less sexy, so gets less airtime on hospital shows).

If you have been to a therapist or doctor, I am sure that you were told to show up 15 minutes early to fill out paperwork. The Oswestry Disability Index is typically one of those paperworks that you have to fill out. It essentially gives us a starting point from which to judge how the symptoms affect your everyday life. The higher the score, the worse you are doing.

  1. “A series of active extension-oriented exercises were performed and progressed…(patients) were instructed to discontinue any activities and to avoid positions that could cause their symptoms to peripheralized or increase in intensity, and were encouraged to stay active.”

Extension oriented exercises are those that I described earlier: the cobra pose and back bending, in addition to prone lying (lying on your belly) and prone on elbows (propped up on your elbows like a kid watching t.v.). It sounds funny that lying on your belly is considered exercise, but if I can charge for it, then it must be exercise. Just kidding. People that lose the ability to bend backwards may be able to start with the lowest level of extension, which in this case is simply prone lying. This is progressed until the patient can perform repeated extension in standing (increasing the lordosis [hollow] in the lower part of the spine.

Participants were instructed to not make themselves any worse. This seems like common sense, but if the person doesn’t understand centralization and peripheralization, this request may not be followed, as sometimes the back pain is more intense compared to the leg symptoms experienced prior to performing extension based movements. The patient must understand that leg symptoms = bad and back symptoms = better.

  1. “The traction protocol was designed with guidance from expert clinicans who use traction frequently and was aimed at a population with lumbar radicular pain consistent with a disc herniation”

This one puzzles me as a clinician. What this says is: “we didn’t really have a good place to start, based on research, so we just called some people that use this treatment to see what they do”. This is the whole “art of science”, in that traction is a traditional based exercise, but its artsy because there’s not much science showing it works.

  1. “Treatments were provided by a licensed physical therapist trained in all study procedures during a 90-minute training session”

Obviously, the people doing the study are well respected and I have met 2 of them. It sounds more glamorous than it actually was-more of a handshake really-but it’s true. That’s my way of saying that these are also considered the “great gurus” of our profession. Now, after saying that…90 minutes?! Really? This is another part that I am frustrated with MDT being used as background information of this study. MDT trained therapists undergo over 80 hours of coursework before sitting for a test in order to be considered “minimally competent”. To say that the researchers learned the procedures in 90 minutes and then compare this to MDT is a travesty. “And that’s all I got to say about that.” A la Mr. Gump.

  1. “The mean +- SD number of treatment sessions was 10.1+- 2.7, with no difference between group.”

What this means is that the people in the study were seen for anywhere from 7-13 visits. Think about that. If you are going to a therapist for more than 13 visits and there has been no effect for back pain, maybe it’s not working.

  1. “…4 participants assigned to EOTA (switched to traction).”

Extension is not for everyone. If a treatment isn’t working or you are getting worse from extension (backward type movements), you should probably switch treatments or go somewhere else if the healthcare practitioner is not comfortable moving you in a way that doesn’t make you worse. There’s a couple of sayings that come to mind in this situation. When I was first learning MDT, many “experienced” therapists told me that to an MDT practitioner “everything looks like a nail, because all you have is a hammer”. This couldn’t be further from the truth and the statement only demonstrates the healthcare practitioner’s ignorance. Don’t get me wrong, I forgive ignorance, but not after having informed you of the total wrongness of the statement. Let’s also talk about experience for a second. I take many students, as I am a credentialed clinical instructor. By the time the student is done with the clinical, I hope for two things: one that he/she is a better clinician walking out compared to walking in and two that the student never becomes a practitioner of 20 years of work with only one year of experience as opposed to 20 years of experience. Moving on, the second saying that comes to mind is “trying to fit a square peg into a round hole.” There are MDT therapists that continue to do this, and the only reason that I know this is because it is still talked about at both courses and conventions. If you have a therapist trying to shove you into a hole you don’t belong in…find another one. Holes are uncomfortable and borderline scary. When you feel this with your healthcare practitioner, you’ll know.

  1. “In other words, matching traction treatment to those patients positive on the subgrouping criteria did not result in greater improvement in pain or disability.”

A long time ago, in a galaxy far far away, there was these researchers that found that a specific group of patients responded better to traction than others. One of the researchers that did the initial study was also an author on the current study. I am impressed when an author can publish a negative (the treatment doesn’t work) study. First, there is a publication bias against this type of study because it is also not as sexy as a study that cures back pain. Second though, this author states that there is a subgroup of patients that can be helped by traction and then later states that maybe there isn’t a subgroup.

  1. “This is consistent with a Cochrane review by Wegner et al that identifies low-to moderate-quality evidence that lumbar traction has little or no impact on disability and pain” and “For patients who are unresponsive to other treatments, using traction to determine if centralization can be achieved may be a reasonable approach, particularly when many medical alternatives include more costly interventions such as injections and surgery.”

Okay, this was a mouthful (imagine typing it all!). The Cochrane review just says that there is a lot of evidence showing that there is moderate evidence that it doesn’t help. Did you get that? We can state, with moderate certainty, that you shouldn’t get have this done to you. This is still prescribed on many physician’s scripts and performed by many therapists.   If your therapist is using this as the go to, then you are no longer ignorant and “Here’s your sign”.

The second aspect of this is more appealing to me and I appreciate the authors’ honesty in writing this. What it essentially says is that if you are a surgical candidate, meaning surgery is the only option, then the kitchen sink should be thrown at you in order to try to fix your problem. If the end result is laying you on a table and cutting you open, either removing a piece of your spine or placing rods and screws in your body, then I am all for traction!

 

In the end, you are a little more educated than you were after reading all of this. I am much more tired after typing all of this. We will all be better off for it in the long run.

Until next time.

If you have back pain, or you know someone that would benefit from an assessment, please pass this information on to them. 

Functional Therapy and Rehabilitation

903 N Infantry Dr. 

Suite 500

815-483-2440