Crook Disc Prognosis

1
Crook Disc Prognosis

• (Or whats worth observing)
• By
• Dr David McGrath

2
Pre 1997 State of Affairs

• Biological Variables Duration of Pain, Past Hx
  of Pain, Leg Pain, BMI, (Disability)
• Psychosocial Variables Education, MMPI, Sickness
  Impact score, Depression, Coping level, Distress,
  Fear
• Work Variables Job Satisfaction, Work Capacity.

3
Fear- Avoidance Model

• Intolerance of activity may not be a biological
  factor but instead have a substantial behavioural
  basis
• Activity intolerance can be explained by a
  combination of pain severity, depression and
  illness behaviour
• Fear avoidance can lead to chronicity
• Basis for cognitive /behavioural Rx

4
Epidemiological Shortcomings

• The results of a survey will be a function of the
  questions asked
• More reliable studies include a large number of
  variables then submit them to multiple regression
  analysis
• Longitudinal studies are best

5
Medline Searches 1999-2005

• LBP
• LBP Natural History
• IDD Natural History
• LBP Disc Prolapse
• LBP Prognostic

6
Ascending Chronological Order

• No judgement about quality of study, only if they
  seem to address prognostic indicators
• Individual studies and literature reviews

7
1999 Far-Lateral Disc Herniations

• N16
• Radicular Pain (concordant with root)
• 3 year study
• 71 Full recovery with no surgery
• Ref (1)

8
1999 VEP Hypothesis

• Common Cause of BP is vertebral end plate
  fracture
• natural history of BP consistent with
  hypothesis
• Ref 2

9
2000 Relation between Intensity, Disability,
Recurrence of LBP

• N94
• Disability ve correlates with pain intensity
• Episodic nature of painful periods -ve correlates
  with functionality at work and home
• Not a static phenomenon
• Ref (3)

10
2000 Exercise Rx and Outcome post Discectomy

• N20
• Exercise vs normal activities
• 4 week exercise program
• Improvements in pain, spinal ROM, disability
  score over non exercise group
• Maintained at 1 year
• Ref(4)

11
2000 N/H Asymptomatic Disc MRI

• N46
• 5 year follow up
• No change to herniations or neural compression
• Disc degeneration progressed in N17
• Minor episodes of LBP in N19
• 5 of 19 obtained Sick Leave
• 5 S/L best predicted by job characteristics and
  job satisfaction and NOT MRI
• Ref(5)

12
2000 Herniated Discs

• N/H of nucleus pulposus herniations complex with
  variables such as inflammation, compression and
  pain altering prognosis
• Relationship between Imaging and LBP or
  radiculopathy not clear
• Value of MRI may be monitoring changes in
  longitudinal studies
• Ref (6)

13
2000 Prospective LBP Study

• N1455
• Questionairre blind survey to adults
• 1/3 lifetime NO LBP
• 4 year new incidence rate
• 40 intermittent LBP
• Ref (7)

14
2000 Socioeconomic aspects MRI

• MRI facilitates medicalization of LBP
• Urging radiologists to avoid unnecessary
  labelling possibly leading to inappropriate
  treatment
• Ref (8)

15
2000 Surgery Disc Prolapse

• Cochrane Review up to 31/12/99
• N27 trials
• Surgical discectomy provides faster relief from
  acute attack than conservative management but ve
  or ve effects on lifetime natural history is
  unclear
• Chemonucleolysis better than placebo but worse
  than surgery
• All surgery similar results
• Ref (9)

16
2002 N/H Sequestrated Disc Herniation

• N49
• Signal Intensity on T2 of herniation compared to
  nucleus pulposus is indicator of potential for
  herniation reduction with time
• Ratio of intensities gt1.2 predictive
• Ref(10)

17
2002 N/H Disc Herniation with Radiculopathy

• Majority of patients suffering radiculopathy
  (Herniated NP) resolve spontaneously without
  surgery or chemonucleolysis
• Ref(11)

18
2002 LBP General Population

• Population of 17,000
• 2 year follow up of LBP patients
• No predictive factors for recovery
• 2 per year new LBP event
• LBP often becomes chronic even when sick leave is
  rare
• Ref(12)

19
2002 N/H Risk Factors Musculoskeletal
Conditions US Army

• N15268
• LBP conditions greatest risk of disability
• Male Risk Factors low pay, diagnosis, shorter
  length service, older, occ category, lower job
  satisfaction, smoking, work stress, physical
  demands.
• Female Risk Lower Educational level
• Ref(13)

20
2003 N/H Spodylolysis Spondylolithesis

• N30 from a population of 500
• Inception ages 6-30
• 45 year follow up
• Unilateral defects NO slippage
• Progression of slip slowed with decades
• No association slip and pain
• Pain and disability scores same as age cohort
• Ref(14)

21
2003 GP perceptions of LBP

• Straightforward condition or complicated?
• Frustration with those that fail to recover
• Biomechanistic approach and good N/H works well
  for most
• Psychological and social dimensions?
• Ref(15)

22
2003 N/H of Aging Spine

• Multiple structural changes
• unrelenting changes leading to scoliosis,
  destabilisation, and rupture of equilibrium
• Ref(16)

23
2003 Risk factors for progression of disc
degeneration

• N796
• Mean age of cohort 54
• Mean BMI 25
• Anterior osteophytes (AO) and disc narrowing
  (DSN)
• AO Progression correlates with age, radiographic
  OA of hip.
• DSN progression correlates age, BP, radiographic
  AO hip and knee
• Nil significance for smoking, physical activity,
  other
• Ref(17)

24
2003 Acute LBP Prognosis

• Literature review
• Most people recover rapidly
• Recurrence common
• Ref(25)

25
2003 LBP Prognosis post MVA

• N4473
• Change in legal entitlement with no common law
  claims
• Claim closure faster
• Higher pain, slower claim closure
• Ref(26)

26
2003 Prognosis Subacute LBP

• N164 Working group
• Duration pain 4-12 weeks
• Predictors, age and pain intensity
• Type of work, not work satisfaction predictive
• Ref(30)

27
2004 Management Chronic LBP

• Opinion
• Monotherapies. Either dont work or limited
  efficacy
• Multidisciplinary based on intensive exercises.
  Improves physical function and has modest effects
  on pain.
• Reductionism. Pathoanatomical diagnosis.
  Treatments are emerging for Z, disc,S/I joints.
• Ref(18)

28
2004 N/H and prognostic indicators of sciatica

• N622 Workers electricity/gas
• Follow up 2 years
• Factors predictive of persistence or recurrence
  were driving at least 2 hours per day, carrying
  heavy loads at work, a high level of
  psychosomatic problems, and pain preceeding onset
  of study.
• Ref (19)

29
2004 Dutch Army minimal intervention LBP

• minimal sports medicine approach
• 2 short training sessions per week
• Study in progress
• Ref(27)

30
2004 Prognostic Factors Recurrent BP

• Prospective cohort, factory Holland
• Prognostic factors, high disability and to a
  lesser degree job satisfaction, low decision
  authority, low social support.
• Ref(28)

31
2004 Scaffolders LBP

• N288 3 year Questionnaire study
• 20 pain every year. 26 nil pain every year.
• High rate of BP incidence, recurrence and
  recovery
• High association of cumulative recurrence with
  manual handling, high job demands, low job
  control
• Weak association with BMI, general health
• Ref(20)

32
2004 Quality of Life Prognostic Indicator of
Acute LBP

• N113
• 5 developed chronic LBP
• Delayed recovery with compensation status,
  initial disability, lower SF-36 (quality of life)
• Lower SF-36 with psychiatric disorders,
  unemployed, comorbidity, job dissatisfaction,
  foreign origin.
• Ref(21)

33
2004 LBP Diagnosis, Rx, Prognosis

• Rxs mostly pain modulating, not cure
• N/H favourable
• A worry is long term disabled
• Fear avoidance behaviour part of disabling
  pathway
• Removing fear and uncertainty. The back is
  robust even if it hurts. Promising approach.
• Ref(22)

34
2004 Outcomes with peri-radicular infiltration,
disc herniation

• N55 Radicular pain
• Mean change VAS 2
• 3 month follow up
• N/H or treatment effect?
• Ref(23)

35
2004 Fear Avoidance Validation LBP

• N388
• Assessment 6 months post treatment
• Fear avoidance score predictive of chronicity
• Ref(31)

36
2004 Ergonomic Interventions LBP

• N1631
• ergonomic Interventions are Successful
• Ref(32)

37
2004 LBP Outcomes Longitudinal Study

• N?
• 1 year follow up
• 75 continuing symptoms
• Baseline pain and general health predicitive of
  continuing BP
• Work satisfaction and negative event predictive
  of pain and disability
• Ref(24)

38
2004 LBP in young NZers

• N969 Birth cohort age26
• LB data questionnaire. BP previous year.
• 54 LBP previous one year with 3-4 times a
  episodes year
• N448 working. No difference between
  professional, clerical, technical, trade or
  production. N56 required S/L
• N13 unable to care for themselves
• Ref (25)

39
2004 Prolotherapy

• Systematic Review
• 4 trials high quality
• Conclusions confounded by clinical heterogeneity
  and co-interventions
• No evidence that prolotherapy alone more
  effective than control injections.
• Ref(26)

40
2004 RTW LBP Prognosis

• Literature Review
• Prognostic Factors P/H of LBP, low level job
  satisfaction, poor general health
• Other factors such as wage, compo, depression,
  physical factors, work postures less significant
• Ref(35)

41
2004 Prognosis Lumber Discectomy

• N48
• Poor outcome predicted by reduced SLR, depression
• Ref(36)

42
2004 Prognostic Value of Functional Capacity
Evaluation

• N226
• Validity of Functional Capacity assessments
  suspect
• Ref(33)

43
2004 Back Schools LBP

• Literature search
• Content of schools has changed
• Moderate evidence schools in occupational setting
  reduce pain, improve function and RTW status cf
  to Other treatments.
• Ref(27)

44
2004 McKenzie

• Systematic Review 6 trials
• Better results than Other for LBP with short term
  pain/disability
• No trials for McKenzie vs placebo
• Insufficient data for neck pain
• Ref(28)

45
2005 Questionnaires. What do they assess

• Main focus on activity limitations
• Considerable variation
• Only a few could be considered acceptably
  validated using WHO criteria
• Ref(29)

46
2005 Behavioural treatment for chronic LBP

• Cochrane database
• Better than waiting list in short term
• No significant difference between behavioural and
  exercise
• No conclusions or recommendations can be made
  from this data
• Ref(30)

47
2005 Multidisciplinary Rehab Prognosis

• N?
• Predictive of poor outcome was number of pre
  admission health care visits
• Ref(37)

48
2005 Acupuncture LBP

• Cochrane data base
• Data does not allow firm conclusions for acute
  LBP
• For chronic LBP better than nil Rx immediately
  after Rx and short term
• No more effective than other Rx
• Data suggests useful adjunct to other Rx
• Ref(31)

49
Conclusions 2005

• Biological variables continue to have predictive
  power. In particular Intensity of pain and
  previous episodes.
• Probably lack of diagnostic precision hampers
  further progress. Imaging findings have poor
  predictive capacity as they distinguish
  structural pathology NOT painful pathology.
  Precision needle techniques are often used as
  therapeutic interventions.
• Spinal physiology needs improving.

50
Conclusions 2005 (contd)

• BP tends to be a recurring problem. We do not
  know why. The structural limits of a component
  are probably exceeded during flare ups. Adaptive
  changes such as tissue remodelling may be
  overwhelmed in the short term or longer.
• Ability is a multi-dimensional concept of
  interaction. Any of these variables can have a
  feedback influence on a vulnerable structure
  through spinal and neural dynamics.

51
Conclusions 2005 (contd)

• In a work environment, work variables will be
  found which influence pain disability.
• In a social milieu, psychosocial variables will
  be identified.

52
Conclusions 2005 (contd)

• Evidence Suggests
• Dont over diagnose
• Dont over treat
• Dont over prognosticate
• Resume normal everyday activities ASAP
• Explain/Reassure. Expect flare ups.

53
Conclusions 2005 (contd)

• Interactive Model might be useful
• What painful structure/s
• What underlying spinal dynamics
• What environment
• What adaptive skills