Purpose of the study and background. An integrated rehabilitation programme was developed and found feasible taking into account the existing evidence base, appropriate theories, and patient and public involvement. The integrated programme encompasses inpatient activities supported by a multidisciplinary team, and integration of knowledge, skills and behaviours in the patient's everyday life. The aim of this trial was to compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain (CLBP). Methods and Results. Comparison of two parallel rehabilitation programmes in a randomised controlled trial including 165 patients with CLBP. The integrated rehabilitation programme comprised an alternation of in total three weeks of inpatient stay and in total 11 weeks of home-based activities. The existing rehabilitation programme comprised a four-week inpatient stay. Primary outcome was changes in disability (Oswestry Disability Index). Secondary outcomes were changes in pain, pain self-efficacy, health related quality of life and depression. Outcomes were collected at baseline and 26-week follow-up. Disability decreased −5.76 (95%CI; −8.31, −3.20) for the integrated programme and −5.64 (95%CI; −8.45, −2.83) for the existing programme. The adjusted difference between the two programmes was −0.28 (95%CI; −4.02, 3.45). No statistically significant difference was found in any of the secondary outcomes. Conclusion. The results of the trial were consistent, showing no significant differences in patients' outcomes when comparing an integrated rehabilitation programme with an existing programme. Conflicts of interest: None. Sources of funding: Aarhus University, The Danish Rheumatism Association and Familien Hede Nielsens Fond

Purposes and Background. Musculoskeletal disorders including as back and neck pain are leading causes of work disability. Effective interventions exist (i.e. functional restoration, multidisciplinary biopsychosocial rehabilitation, workplace-based interventions, etc.), but it is difficult to select the optimal intervention for specific patients. The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions. The WATT algorithm categorizes patients based on individual, occupational, and clinical characteristics according to likelihood of successful return-to-work following rehabilitation. Internal validation showed acceptable classification accuracy, but WATT has not been tested beyond the original development sample. Our purpose was to externally validate the WATT. Methods and Results. A population-based cohort design was used, with administrative and clinical data extracted from a Canadian provincial compensation database. Data were available on workers being considered for rehabilitation between January 2013 and December 2016. Data was obtained on patient characteristics (ie. age, sex, education level), clinical factors (ie. diagnosis, part of body affected, pain and disability ratings), occupational factors (ie. occupation, employment status, modified work availability), type of rehabilitation program undertaken, and return-to-work outcomes (receipt of wage replacement benefits 30 days after assessment). Analysis included classification accuracy statistics of WATT recommendations for selecting interventions that lead to successful RTW outcomes. The sample included 5296 workers of which 33% had spinal conditions. Sensitivity of the WATT was 0.35 while specificity was 0.83. Overall accuracy was 73%. Conclusion. Accuracy of the WATT for selecting successful rehabilitation programs was modest. Algorithm revision and further validation is needed. No conflicts of interest. Sources of funding: Funding was provided by the Workers' Compensation Board of Alberta

Purpose. Lumbar paraspinal muscle dysfunction and low back pain are strongly correlated. Muscle atrophy is common in LBP and is recognised by MRI scan. Corticosteroid injections and physical rehabilitation programs are advocated for treatment of LBP. The purpose is to evaluate efficacy of specific lumbar multifidus muscle retraining exercises and perifacet multifidus injections in treatment of Low Back Pain (LBP) and referred leg pain. Method. 63 patients with non-specific LBP, with or without leg pain, were randomised to three treatment groups. MR images of paraspinal muscle and the atrophy classified. A-Control group, standard physiotherapy for 10 weeks. B-Multifidus rehabilitation program for 10 weeks. C-Perifacet injection (multifidus injection) with methylprednisolone. ODI was primary outcome measure and the SF-36, modified Zung Depression Index and others were secondary outcome measures. Results. 56 patients completed trial. ODI improved from a mean of 29.9 to 25.9, but there were no statistically significant differences between groups. 62% of patients were at risk/had major psychological overlay. LBP improved most in group C (Perifacet injection) (P< 0.02), mean improvement in SF-36 bodily pain score was 21.2 (with a 95% CI of 2.1-44.0) while PF and SF were improved most in group B (multifidus rehabilitation) (P< 0.03). Conclusion. Perifacet injection and a multifidus retraining program are more effective than standard physiotherapy in relieving pain and improving physical capacity respectively. Multifidus rehabilitation program is the recommended treatment for non-specific LBP, as the ultimate goal should be to restore function. Perhaps the combination of perifacet injection to relieve pain followed by multifidus retraining program is the best treatment option. No change in the multifidus muscle was seen over time

Background. Free From Pain (aka Fear Reduction, Exercise Early with Food from plants, Rest and relaxation, Organisation and Motivation to decrease Pain from Arthritis and Increase Natural Strength) is a functional rehabilitation programme to combat sarcopenia and musculoskeletal pain in seniors. It is also published as a book (ISBN-0995676941). The aim of this audit was to evaluate the safety and suitability of the exercises and the usefulness of the exercise book. Methods and Results. Participants were volunteers who paid to attend the Free From Pain Exercise programme. Participants evaluated the exercises using a 5-point Likert scale and the Exercise Book using the Usefulness Scale for Patient Information Material (USE). 30 participants attended the Free From Pain programme. 26 participants completed the questionnaire. This included 20 females and 6 males, with a mean age of 76 years. The mean scores on the 0 to 5 Likert scales were A) Exercises were suitable? 4.69; B) Exercises were safe? 4.58; C) Absence of any injury or medical event whilst exercising? 4.58; D) Covered all body parts? 4.38; E) Easy to do at home? 4.42; F) Encouraged to do more exercise? 4.42; G) Recommend to family and friends? 4.50. The mean scores of the cognitive, emotional, and behavioural sub domains of the USE scale, scored 0 to 30, were 25.23, 23.73 and 23.69, respectively. Conclusion. The pre-pilot study suggests that the suggested exercises are safe and suitable for seniors, and that the exercise book is holistically useful. Conflict of Interest: G Ampat sells the Free From Pain Exercise book online through Amazon and other platforms. S Rhodes and J Sims are employed by Talita Cumi Ltd, of which Free From Pain is a trading name. Jacqueline Howard is a medical student and has no conflict of interest. Sources of funding: No funding was obtained

To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients. A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively. After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL). The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes

Purpose. The behavioural change wheel methodology and social cognitive theory were combined to inform and develop a rehabilitation programme following lumbar fusion surgery (REFS). This qualitative study evaluated participant's experiences of lumbar fusion surgery, including REFS, to identify valued programme content (‘active ingredients’). Background. A feasibility-RCT suggested REFS achieved a meaningful impact in disability and pain self-efficacy compared to ‘usual care’ (p=0.014, p=0.007). In keeping with MRC guidance a qualitative evaluation was undertaken to understand possible mechanisms of action. Methods. Thematic analysis was utilised on data from semi-structured, face-to-face interviews, in a purposive sample (REFS n=10, ‘usual care’ n=10). Results. Three themes (8 sub-themes) were identified, which illuminated the experiences of 1) the impact of living with a chronic lumbar disorder 2) reflections on recovery, and 3) the experience of rehabilitation with(out) REFS. REFS participants identified valued programme content including the opportunity for vicarious learning, the shared rehabilitation experience, and expert physiotherapy. They were unable to identify pre-eminent programme content, in keeping with inter-dependent ‘active ingredients’. Abstraction with the overarching theme of ‘loss of self’ was evident for analysis across all themes. Conclusion. In conclusion the findings were theoretically congruous with other published works e.g. recent mega-ethnographic review of patients experience of chronic non-malignant pain. Two emergent areas were identified to inform future REFS iterations and better understand potential mechanisms of action. 1-Participants fear of harm appears directly attributable to the instillation of metalware, this association is mediated by inadequate advice. 2-Lumbar fusion surgery is not perceived as elective. No conflicts of interest. Funding; NIHR (Doctoral fellowship, awarded to J Greenwood)

Many operations have been recommended to treat Pars Interarticularis fractures that have separated and are persistently symptomatic, but little other than conservative treatment has been recommended for symptomatic incomplete fractures. 10 consecutive patients aged 15–28 [mean 21.7 years] were treated operatively between 2010–2014. All but one were either professional athletes [3 cricketers, 2 athletics, 1 soccer] or academy cricketers [3 patients]. 8 patients had unilateral fractures, and two had bilateral fractures at the same level. The duration of pre-operative pain and disability with exercise ranged from 4–24 months [mean 15.4 months]. The operation consists of a percutaneous compression screw inserted through a 1.5cm midline skin incision under fluoroscopic guidance: 6 cases were also checked with the O-arm intra-operatively. Post-operation the patients were mobilised with a simple corset and discharged the following day with a customised rehabilitation program. All 12 fractures in 10 patients healed as demonstrated on post-operative CT scans at between 3–6 months. One patient had the screw revised at 24 hours for an asymptomatic breach, and one patient developed a halo around the fracture site without screw loosening, and had a successful revision operation to remove the screw and graft the pars from the screw channel. All patients achieved a full return to asymptomatic activity, within a timescale of 4–12 months post-surgery, depending on the sport. Athletes that have persistent symptoms from incomplete pars interarticularis fractures should consider percutaneous fixation rather than undergoing prolonged or repeated periods of rest

Purpose of the study and background. Physical activity and exercise therapy are among the guideline recommendations for the rehabilitation of people with chronic low back pain (CLBP ≥ 3 months); however, patient adherence is often poor. CONNECT is a theory-based communication skills training programme designed to enhance physiotherapists' support of their CLBP patients' psychological needs in order to increase adherence to their home-based rehabilitation programme. Methods and results. The CONNECT trial [Current Controlled Trials ISRCTN63723433] included six Dublin-area public clinics and their physiotherapists (n = 24) who received eight hours of communication skills training from a psychologist [experimental group] and physiotherapists (n = 26) from six equivalent clinics who formed a treatment as usual pragmatic control condition. New patients (n = 255, 54% female) diagnosed with CLBP and receiving physiotherapy at one of these clinics completed ratings of home-based adherence at 1, 4, 12, and 24 weeks after their initial treatment session; 24 weeks was the primary endpoint. Due to the nature of the intervention, physiotherapists were aware of treatment allocation; patients and assessors were blinded. Intention to treat analysis using a linear mixed model approach indicated that patients in the experimental group rated their home-based adherence significantly higher than patients in the control condition across time-points (P = .01), but the difference was not significant at the 24-week follow-up (P > .05). Conclusions. The CONNECT intervention had a positive effect on patients' self-rated adherence to home-based rehabilitation for CLBP, but the impact was not maintained over 24 weeks. Further analysis from the CONNECT trial will investigate its effects on pain and function, as well as hypothesised mediators of change

Introduction. Adolescent idiopathic scoliosis accounts for 80–85% of all lateral curvatures, and negatively affects pulmonary functions. The concave rib osteotomy technique is designed to provide additional mobility and flexibility of the spine, especially for rigid curves during correction. Only a few studies have investigated the effect of concave rib osteotomy on pulmonary functions. Methods. We undertook a prospective study of 127 patients who underwent posterior spinal fusion for correction of adolescent idiopathic scoliosis. Patients were divided according to their Cobb angle into two groups: group 1 (n=78) with a Cobb angle greater than 70° who underwent an additional concave rib osteotomy (CRO); and group 2 (n=49) with a Cobb angle less than 70° who did not (NCRO). All patients received a programme of pulmonary rehabilitation immediately after the operation for 1 year. Vital capacity (VC) and peak expiratory flow rate (PEF) were measured preoperatively, at 3 months and 12 months postoperatively, and at 5 years postoperatively. Results. In group 1 (CRO), the mean Cobb angle was 82·2° (□}22·78°) preoperatively and 10·9°(□}8·33°) at 1 year follow-up (87% correction). In group 2 (NCRO), the mean Cobb angle was 62·77° (□}18·43°) preoperatively and 6·9°(□}7·69°) at 1 year follow-up (89% correction). Preoperatively there was no significant difference in pulmonary functions between the two groups, with mean VC of 85·2% (□}33·7) in the CRO group and 90·1% (□}38·9) in the NCRO group (p=0·22) and mean PEF of 59·8% (□}27·4) and 52·2% (□}30·3), respectively (p=0·32). Postoperatively, mean VC was 40·4% (□}23·74) in the CRO group (52% reduction) and 48·05% (□}29·13) in the NCRO group (47% reduction) (p=0·05). Mean PEF was 27·38% (□}17·35) in the CRO group (54% reduction) and 34·1% (□}21·8) in the NRCO group (45% reduction) (p=0·02). 12 months postoperatively, mean VC was 102·4% (□}31·5; 150% improvement) and 103·5% (□}40; 115% improvement), respectively (p=0·43). Mean PEF was 76·2% (□}24·5; 170% improvement) and 73·5% (□}35·6; 117% improvement), respectively (p=0·32). 5 years postoperatively, mean VC was 111·84% (□}33·95; 0·09% improvement) and 114% (□}29·6; 0·10% improvement), respectively (p=0·086). Mean PEF was 82·56% (□}36·8; 0·08% improvement) and 82·3% (□}27·1; 0·11% improvement), respectively (p=0·26). Conclusions. Concave rib osteotomy technique has a definite immediate effect on pulmonary functions postoperatively; however, this difference resolves with application of pulmonary rehabilitation programme in both groups and outcome is similar 1 year postoperatively. 5 years later we recorded no significant differences between groups

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes.

A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group.

In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes.

Cite this article: Bone Joint J 2013;95-B:81–9.