Christy Tomkins-Lane

Does physical activity influence the relationship between low back pain and obesity

BACKGROUND CONTEXTnEvidence supporting an association between obesity and low back pain (LBP) continues to grow; yet little is known about the cause and effect of this relationship. Even less is known about the mechanisms linking the two. Physical activity is a logical suspect, but no study has demonstrated its role.nnnPURPOSEnThis study was designed to examine the interrelationship between physical activity, obesity, and LBP. The specific aims were to determine if obesity is a risk factor for LBP in the U.S. population, measure the strength of any observed association, and evaluate the role of physical activity in modulating this association.nnnSTUDY DESIGN/SETTINGnA cross-sectional U.S. population-based study.nnnPATIENT SAMPLEnA cohort of 6,796 adults from the 2003-2004 National Health and Nutrition Examination Survey.nnnOUTCOME MEASURESnDemographic information, an in-depth health questionnaire, physical examination details, and 7-day free-living physical activity monitoring using accelerometry (ActiGraph AM-7164; ActiGraph, Pensacola, FL, USA).nnnMETHODSnLBP status was determined by questionnaire response. Body mass index (BMI) was calculated during physical examination and divided here into four groups (normal weight <25, overweight 25-30, obese 31-35, and ultraobese 36+). Summary measures of physical activity were computed based on intensity cutoffs, percentile intensities, and bout. Demographics, social history, and comorbid health conditions were used to build adjusted weighted logistic regression models constructed using Akaike Information Criterion. All displayed estimates are significant at level <.05. No external funding was received to support this study. None of the authors report conflicts of interest directly related to the specific subject matter of this manuscript.nnnRESULTSnIn the U.S. population, the risk of low LBP increases in step with BMI from 2.9% for normal BMI (20-25) to 5.2% for overweight (26-30), 7.7% for obese (31-35), and 11.6% for ultraobese (36+). Smoking is consistently the strongest predictor of LBP across the BMI spectrum (odds ratio 1.6-2.9). Physical activity also modulates these risks. In the overall model, the best physical activity predictors of LBP are in the moderate and high intensity ranges with small effects (odds ratio 0.98 and 0.996 per standard deviation increase, respectively). When broken down by BMI, time spent in sedentary and moderate activity ranges demonstrate more robust influences on LBP status in the overweight, obese, and ultraobese groups.nnnCONCLUSIONSnIncreased BMI is a risk factor for back pain in Americans. More important, the role of physical activity in mitigating back pain risk is shown to be of greater consequence in the overweight and obese populations.

Validity and reproducibility of self-report measures of walking capacity in lumbar spinal stenosis.

Study Design. Measurement (validity) study. Objective. Examine validity and reproducibility of self-report measures of walking capacity for use in patients with lumbar spinal stenosis (LSS). Summary of Background Data. Treatment outcomes in patients with LSS are often determined using data from self-report questionnaires. Despite some validity evidence available to support the use of self-report instruments in the evaluation of walking capacity in LSS, it is not certain that the construct being tapped using any of the self-report measures is, in fact, walking capacity. Methods. Validity of the Physical Function Scale of the Swiss Spinal Stenosis Questionnaire, the Oswestry Disability Index (ODI), self-predicted walking capacity (distance in meters) and a number of single item walking capacity questions was evaluated through comparison with a criterion measure of walking capacity, the Self-Paced Walking Test, in patients with LSS. Test-retest reproducibility was also examined for each of the self-report measures. Results. Subjects included 49 patients (65.8 ± 10.0 years of age) with LSS confirmed on imaging and by a spine specialist surgeon. The measures found to be most highly associated with the criterion Self-Paced Walking Test were the walking distance item from the ODI (r = 0.83) and self-reported walking capacity in meters (with the aid of a distance reference) (r = 0.80). Reported walking capacity in meters had the lowest test-retest reproducibility (intraclass correlation coefficient = 0.65) of the measures studied. Conclusion. This study provides new information to help guide health professionals and researchers in the selection of appropriate outcome tools when examining walking in an LSS population. Study results support the use of the Physical Function Scale, self-reported walking distance, and the walking specific items from the ODI and the Physical Function Scale.

Management of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) affects more than 200u2009000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Surgical versus non-surgical treatment for lumbar spinal stenosis

BACKGROUNDnLumbar spinal stenosis (LSS) is a debilitating condition associated with degeneration of the spine with aging.nnnOBJECTIVESnTo evaluate the effectiveness of different types of surgery compared with different types of non-surgical interventions in adults with symptomatic LSS. Primary outcomes included quality of life, disability, function and pain. Also, to consider complication rates and side effects, and to evaluate short-, intermediate- and long-term outcomes (six months, six months to two years, five years or longer).nnnSEARCH METHODSnWe searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases and two trials registries up to February 2015. We also screened reference lists and conference proceedings related to treatment of the spine.nnnSELECTION CRITERIAnRandomised controlled trials (RCTs) comparing surgical versus non-operative treatments in participants with lumbar spinal stenosis confirmed by clinical and imaging findings.nnnDATA COLLECTION AND ANALYSISnFor data collection and analysis, we followed methods guidelines of the Cochrane Back and Neck Review Group (Furlan 2009) and those provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).nnnMAIN RESULTSnFrom the 12,966 citations screened, we assessed 26 full-text articles and included five RCTs (643 participants).Low-quality evidence from the meta-analysis performed on two trials using the Oswestry Disability Index (pain-related disability) to compare direct decompression with or without fusion versus multi-modal non-operative care showed no significant differences at six months (mean difference (MD) -3.66, 95% confidence interval (CI) -10.12 to 2.80) and at one year (MD -6.18, 95% CI -15.03 to 2.66). At 24 months, significant differences favoured decompression (MD -4.43, 95% CI -7.91 to -0.96). Low-quality evidence from one small study revealed no difference in pain outcomes between decompression and usual conservative care (bracing and exercise) at three months (risk ratio (RR) 1.38, 95% CI 0.22 to 8.59), four years (RR 7.50, 95% CI 1.00 to 56.48) and 10 years (RR 4.09, 95% CI 0.95 to 17.58).Low-quality evidence from one small study suggested no differences at six weeks in the Oswestry Disability Index for patients treated with minimally invasive mild decompression versus those treated with epidural steroid injections (MD 5.70, 95% CI 0.57 to 10.83; 38 participants). Zurich Claudication Questionnaire (ZCQ) results were better for epidural injection at six weeks (MD -0.60, 95% CI -0.92 to -0.28), and visual analogue scale (VAS) improvements were better in the mild decompression group (MD 2.40, 95% CI 1.92 to 2.88). At 12 weeks, many cross-overs prevented further analysis.Low-quality evidence from a single study including 191 participants favoured the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity and physical function.All remaining studies reported complications associated with surgery and conservative side effects of treatment: Two studies reported no major complications in the surgical group, and the other study reported complications in 10% and 24% of participants, including spinous process fracture, coronary ischaemia, respiratory distress, haematoma, stroke, risk of reoperation and death due to pulmonary oedema.nnnAUTHORS CONCLUSIONSnWe have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.

What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review

AbstractPurposenTo investigate what interventions can improve walking ability in neurogenic claudication with lumbar spinal stenosis.MethodsnWe searched CENTRAL, Medline, EMBASE, CINAHL and ICL databases up to June 2012. Only randomized controlled trials published in English and measuring walking ability were included. Data extraction, risk of bias assessment, and quality of the evidence evaluation were performed using methods of the Cochrane Back Review Group.ResultsnWe accepted 18 studies with 1,220 participants. There is very low quality evidence that calcitonin is no better than placebo or paracetamol regardless of mode of administration. There is low quality evidence that prostaglandins, and very low quality evidence that gabapentin or methylcobalamin, improves walking distance. There is low and very low quality evidence that physical therapy was no better in improving walking ability compared to no treatment, oral diclofenac plus home exercises, or combined manual therapy and exercise. There is very low quality evidence that epidural injections improve walking distance up to 2xa0weeks compared to placebo. There is low- and very low-quality evidence that various direct decompression surgical techniques show similar significant improvements in walking ability. There is low quality evidence that direct decompression is no better than non-operative treatment in improving walking ability. There is very low quality evidence that indirect decompression improves walking ability compared to non-operative treatment.ConclusionsCurrent evidence for surgical and non-surgical treatment to improve walking ability is of low and very low quality and thus prohibits recommendations to guide clinical practice.

ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.

Study Design. Delphi. Objective. The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. Methods. Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. Results. A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were “leg or buttock pain while walking,” “flex forward to relieve symptoms,” “feel relief when using a shopping cart or bicycle,” “motor or sensory disturbance while walking,” “normal and symmetric foot pulses,” “lower extremity weakness,” and “low back pain.” Significant change in certainty ceased after six questions at 80% (Pu200a<u200a.05). Conclusion. This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of “seven history items” that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. Level of Evidence: 2

Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study

Study Design. Delphi. Objective. The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. Methods. Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. Results. A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were “leg or buttock pain while walking,” “flex forward to relieve symptoms,” “feel relief when using a shopping cart or bicycle,” “motor or sensory disturbance while walking,” “normal and symmetric foot pulses,” “lower extremity weakness,” and “low back pain.” Significant change in certainty ceased after six questions at 80% (Pu200a<u200a.05). Conclusion. This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of “seven history items” that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. Level of Evidence: 2

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot

BACKGROUND CONTEXTnOwing to mobility limitations, people with lumbar spinal stenosis (LSS) are at risk for diseases of inactivity, including obesity. Therefore, weight management in LSS is critical. Body mass index is the strongest predictor of function in LSS, suggesting that weight loss may promote physical activity and provide a unique treatment option. We propose a lifestyle modification approach of physical activity and nutrition education, delivered through an e-health platform.nnnPURPOSEnThe purpose of this study was to develop and pilot an e-health intervention aimed at increasing physical activity and decreasing fat mass in people with LSS.nnnSTUDY DESIGNnThe study design was based on intervention development and pilot.nnnPATIENT SAMPLEnTen overweight or obese individuals with LSS were confirmed clinically and on imaging.nnnOUTCOME MEASURESnSelf-reported measures were food record, Short-Form 36 (SF-36), pain scales, Swiss Spinal Stenosis Symptom and Physical Function Scales, Oswestry Disability Index (ODI), Pain Catastrophizing Questionnaire, Tampa Scale for Kinesiophobia, Center for Epidemiologic Studies(Depression) Scale, Behavioral Regular in Exercise Questionnaire, and Regulation for Eating Behavior Scale and physiologic measures were dual-energy X-ray absorptiometry (DXA), blood draw, 7-day accelerometry, self-paced walking test, and balance test.nnnMETHODSnThe e-health platform was developed.nnnINTERVENTIONnduring Week 1, participants received a pedometer and a personalized consultation with a dietitian and an exercise physiologist. For 12 weeks, participants logged on to the e-health Web site to access personal step goals, nutrition education videos, and a discussion board. Follow-up occurred at Week 13.nnnRESULTSnNine participants had a mean age of 67.5±6.7 years (60% women). Significant improvements were observed for fat mass (DXA), trunk fat mass, symptom severity (Swiss Symptom Scale), energy intake, maximum continuous activity (accelerometry), and mental health (SF-36) (p<.05). Nonsignificant improvements were observed for waist circumference, pain, ODI, and obesity biomarkers. Seventy percent lost weight, 50% increased walking capacity, and 60% increased quality of life. The mean increase in steps was 15%.nnnCONCLUSIONSnThe spinal stenosis pedometer and nutrition lifestyle intervention was shown to be feasible, attractive to participants, and effective in this small sample. This intervention provides people with LSS the opportunity to participate in their own health management, potentially improving access to care. Efficacy is currently being assessed in a randomized trial.

A review of activity monitors as a new technology for objectifying function in lumbar spinal stenosis.

The purpose of this review article is to introduce the concept of activity monitoring, and to discuss the application of accelerometry in rehabilitation research and clinical practice using lumbar spinal stenosis as a model. Function is a complex concept, and changes in function have historically been challenging to measure. The International Classification of Functioning (ICF) defines two distinct components of function: capacity and performance. Capacity, the ability to perform a given task in a controlled environment can be measured through any number of existing functional measures. Performance, defined as activities performed on a day to day basis in the context of real life is challenging to measure, yet important in identifying the impact of pathology on real life. Recent advances in technology have allowed us to begin to measure performance, using activity monitors (accelerometers). Activity monitoring has the potential to change our concepts of outcomes, and as a result, expand our ideas about appropriateness of interventions in rehabilitation. Researchers and clinicians might benefit from using the new technology of activity monitors to measure the impact of intervention and to assess function. Therefore, this review will discuss the concept of activity monitoring and highlight potential uses for activity monitors in spine research and clinical care.

Surgical Versus Nonsurgical Treatment for Lumbar Spinal Stenosis.

Study Design. A systematic review. Objectives. The aim of this study is to evaluate the effectiveness of different types of surgery compared with different types of nonsurgical interventions in adults with symptomatic lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a debilitating condition associated with degeneration of the spine with aging. People with LSS experience a range of symptoms, including back pain, leg pain, numbness and tingling in the legs, and reduced physical function. Main treatment options are surgery, physical therapy, exercise, braces, and injections into the spine. Methods. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases, and two trials registries up to February 2015, reference lists, and conference proceedings related to treatment of the spine. Randomized controlled trials (RCTs) compared surgical versus nonoperative treatments in participants with LSS. Outcomes included quality of life, disability, function, pain, complication rates, and side effects. Results. From the 12,966 citations screened, we included five RCTs (643 participants). Three studies compared spine surgery versus various types of nonsurgical treatment. It is difficult to draw conclusions from these studies because nonsurgical treatments were inadequately described. One study that compared surgery versus bracing and exercise found no differences in pain. Another study compared surgery versus spinal injections and found better physical function with injections, and better pain relief with surgery at six weeks. Still another trial compared surgery with an implanted device versus nonsurgical care. This study reported favorable outcomes of surgery for symptoms and physical function. Conclusion. We cannot conclude on the basis of this review whether surgical or nonsurgical treatment is better for individuals with LSS. Nevertheless, we can report on the high rate of effects reported in three of five surgical groups, ranging from 10% to 24%. No side effects were reported for any of the conservative treatment options. Level of Evidence: 1