Ulnar Nerve Compression Diagnosis and Treatment Options

The ulnar nerve runs to the pinky side of the hand where it is responsible for both muscle actions and sensations.  Because the nerve must travel through a small canal at the wrist, the nerve can become entrapped resulting in pinky and or ring finger numbness as well as difficulty pulling your thumb in towards your hand and using your pinky, depending on which portion of the nerve is compressed.

Ulnar nerve compression can be caused by numerous factors.  Soft tissue tumors can impinge on the nerve in the narrow space it has to travel into the palm.  Long-term trauma can also cause nerve damage, like vibrations (jackhammer use), prolonged pressure on the wrist (i.e. weight lifting and bike riding), which is often conservatively treated by rest and occupational adjustments. Acute trauma, like wrist bone fractures can also impinge on the ulnar nerve. Arthritis and metabolic conditions, such as alcoholism, hypothyroidism or diabetes can also play a role.

When diagnosing patients with ulnar nerve entrapment, doctors must consider multiple sites higher in the arm that could potentially be causing the problems at the hand and take a careful history including occupational use and length and duration of the hand numbness or muscle weakness. Examination should also include strength tests, sensation testing, ulnar nerve testing along its path through the arm, and a vascular examination.  All results should be compared to the uninvolved side.  MRI, x-rays, and nerve conduction tests can also help determine exactly why and where the nerve is being compressed.

Ulnar nerve compression is first treated by nonsurgical management, such as rest or physical therapy.  If symptoms do not resolve within two to four months surgery is recommended. Surgery involves either removal of the compressive tissue, wrist fracture repair, or open up the canal through which the ulnar nerve runs.  Evidence is sparse regarding surgical outcomes, however the existing studies show good results with surgery.

Review of Management Strategies for Acute Shoulder Dislocations

Due to a scarcity of bony restraints and minimal articular contact the shoulder joint has the greatest range of motion of any joint in the body. It relies on soft-tissue restraints for stability, including the capsule, musculature and ligaments. Because of this, the shoulder joint is at high risk for dislocation. There are many shoulder dislocation reduction techniques. Many of these have been described in the literature, however, there is lack of comparative studies on the various techniques. It is essential that there be thorough understanding of anatomy, classification of the dislocation, type of reduction maneuver and different anesthetic technique for successful management of this injury.

The shoulder joint is held in a reduced position through both static and dynamic stabilizers. Static stabilizers include the glenoid fossa, labrum, capsule and glenohumeral ligaments. They work by maintaining the continuity of the joint through reinforcing support at end ranges of motion. For example, the labrum increases shoulder stability by contributing 50 per cent of the glenoid cavity depth and increasing the total surface area. The glenohumeral ligaments resist translation. Dynamic stabilizers include the deltoid, biceps, rotator cuff and scapular stabilizing muscles. They function via the neuromuscular system by actively stabilizing the moving joint at mid ranges of motion. For example, the rotator cuff provides a dynamic compression of the humeral head into the fossa of the shoulder joint. The trapezius, rhomboids, latissimus dorsi, serratus anterior and levator scapulae muscles actively stabilize the scapula to allow for increased stability. Shoulder dislocations are classified as either traumatic or atraumatic. They are further classified by the direction of dislocation either anterior, posterior or inferior. Anterior shoulder dislocation is the most common at ninety seven percent.

Despite that there are multiple reduction maneuvers available some general principles apply to acute management of shoulder dislocations. A dislocation should be reduced as quickly as possible to avoid muscular spasms and neurovascular compromise and it’s important that all of this should be done in a gentle and technically sound closed reduction process. If the reduction is tended to quickly before muscular spasm sets in, often it can be done without local pain medication. Anesthesia may be required and it is recommended that intra-articular block be used first, while reserving sedation for the more difficult cases. Like mentioned previously, multiple reduction techniques exist. For anterior dislocations popular reduction methods include: Hippocrates, Traction-countertraction, Chair, Kocher, Stimpson, Milch, External Rotation, Spaso, Eskimo, Scapular Manipulation and FARES (Fast, Reliable and Safe). Posterior dislocations are less common occurring only three percent of the time and are often more difficult to diagnose. Closed reductions are often difficult and may require at least two operators and sedation. Inferior shoulder dislocations are even more rare, occurring less than one percent of all dislocations. Two different reduction methods are used in inferior dislocation management known as Traction-Countertraction and Two-step.

Only a few studies have looked at and compared different methods of closed reduction. In a study of 111 patients, the Milch and Kocher techniques were compared. They found no difference between the two in success rate but the Milch technique was found to be more successful in patients over forty years of age when performed within a timeframe of four hours of dislocation. In a randomized study with patients who suffered anterior dislocation were treated with either the Stimson or Milch technique. With the Milch technique success rate was 82 per cent on first reduction compared to only 28 per cent for the Stimson technique. Another randomized control trial of 154 patients with anterior dislocation demonstrated that the FARES method was more successful, quicker and less painful than the Kocher and Hippocrates techniques. After successful reduction, rehabilitation usually occurs to maximize range of motion and to regain stability. There is usually a minimum period of immobilization lasting three to four weeks. Gradual return to activity will be achieved after this.

The authors of this review conclude that while there are many methods for management of acute dislocation, the orthopedic surgeon must be well versed in different techniques to best decide the appropriate approach for each individual patient.

Updated Review of Management Strategies for Finger Flexor Tendon Injuries in Zone II

History has shown that injuries located in zone II of the hand, classified between the distal palmar crease and the flexor digitorum superficialis (FDS) insertion, have been particularly challenging to repair. This is due to the fact that tendon gliding must be restored within a tight sheath while minimizing the adhesions in surrounding tissues. At one point surgery in this area was deemed “no man’s land”. However, there have been remarkable advances in the understanding of healing characteristics, both mechanically and histologically of tendons. Over time, there has been a shift toward surgical repair of finger flexor tendon injuries, including in the area or zone II. While injuries to the flexor tendons are relatively rare among acute hand injuries (less than one percent) there has been extensive research into the injury and subsequent repair.

The FDS and the flexor digitorum profundus FDP originate from the elbow and proximal ulna and interosseous membrane respectively. The muscles divide into tendons in the mid forearm and travel through the carpal tunnel toward each of the fingers. In zone II the FDS tendon splits with each slip traveling laterally and dorsally to the FDP tendon. The FDS slips attach separately along the palmar aspect of the middle phalanx bone while the FDP tendons further attach along the base of the last or distal phalanx. The finger possesses a series of flexor pulleys that allow for maximal mechanical efficiency of the flexor system. Tendon healing occurs through a combined extrinsic cellular response and intrinsic ability that the flexor tendons posses to heal themselves after injury. It has been shown that early mobilization of a repaired tendon shifts the healing process to an intrinsic mechanism to allow for collagen to be laid down in a pattern that closely replicates the native tendon and results in diminished amount of adhesions forming.

Evaluation of the patient with a flexor tendon injury should include a thorough history and physical examination to identify the type and extent of the injury. This should also include a neurovascular examination to identify if there was additionally any injury to the nerves or blood supply to the area. Within zone II, the FDP tendon is the more commonly injured of the two tendons. With a FDP repair, recent studies have suggested that there be partial excision of up to 50 per cent into the A2 pulley and complete division of the A4 pulley to allow for increased tendon gliding. Whereas, traditionally, many surgeons would have deemed these pulley inviolable. There have been many suture configurations described, the author of this review stresses that the treating surgeon us a technique that allows for properly coapted repair in the absence of gapping and minimal trauma to the tendon edges. It was also recommended that at least four core suture strands are used in surgical repair to minimize the risk of rupture. The senior author of this review paper’s preferred technique is a modified Kessler suture configuration that adds a separate cross-locked cruciate technique especially if there is an increased risk for adhesions anticipated. Mechanical testing demonstrated that ideal placement of the core suture was seven to ten mm from the repair site. Gapping or elongation of the repair site must be avoided as they can affect the strength of the repaired tendon thus the use of peripheral suture in addition to the core suture are important. The peripheral suture both minimizes the bulk of the repair and can help prevent elongation of the tendon or gapping. Whether to pursue repairing a FDS tendon in zone II depends on the exact location of the injury. If warranted, to limit bulk of the repaired tendon under the A2 pulley, surgeons will excise one of the slips of the FDS and repair the other to allow for improved gliding of the repaired tendons.

Postoperative rehabilitation is a very important process of the flexor tendon repair. Like mentioned previously early mobilization enhances the strength of the repair site and decreases possible adhesions. It is the discretion of the surgeon to chose either early passive or early active motion protocol. It is recommended that range of motion exercises are not initiated until at minimum four days post surgery but not later than seven days post surgery. A systematic review of the literature demonstrated that both early passive and early active mobilization protocols deliver adequate motion. In the only randomized controlled trial that compared the two protocols it was found that patients who underwent an active place-and-hold protocol showed greater ROM, less flexion contractures and greater patient satisfaction. It was noted that it’s important for the surgeon to select a rehabilitation protocol that best matches the patients ability to comply with the protocol’s restrictions.

It is difficult to draw conclusions on the reported outcomes of flexor tendon repairs due to the heterogeneity of the the rehabilitation protocols and studies on flexor tendon repairs, the variability in reporting of the finger motion and the lack of use of patient-reported outcome measures. Patients with multiple finger involvement, have additional nerve injury and those who smoke were found to more likely have poor outcomes.

Review of Management for Nerve Entrapment Issues in the Foot and Ankle

While relatively uncommon, nerves can become entrapped in the lower leg and ankle. A recent updated review article touched upon management of these diagnoses. The author stated that it’s important to establish an accurate diagnosis through which physicians will rely on a thorough physical examination and must additionally possess a thorough understanding of relevant anatomy. Electrodiagnostic testing, including nerve conduction velocity NVC and electromyography EMGs and advanced imaging such as magnetic resonance imaging MRI and ultrasonography can assist with localizing the area of entrapment and contributing factors.

Tarsal tunnel syndrome occurs when the tibial nerve is entrapped and can be further divided into proximal syndrome and distal syndrome. Proximal tarsal tunnel syndrome is the most common and occurs when the tibial nerve is compressed in the tarsal tunnel proper. Patients will typically present with diffuse pain along the inside of the ankle and bottom of the foot. It is often described as burning, shooting, electric, tingling and numbing. After comprehensive physical examination, radiographs and MRI or ultrasonography may be used to identify soft tissue or bony contributions. Electrodiagnostic studies may be used to confirm entrapment but they cannot be used to exclusively rule in or out tarsal tunnel syndrome. Typically non-surgical management is used first including anti-inflammatory medication, activity modifications, physical therapy, and eliminating use of compressive clothing or footwear. Surgical release is only recommended when these conservative measures have failed. Full release of the flexor retinaculum is recommended. It was also found that early diagnosis and intervention provided improved outcome than those who had more chronic symptoms.

Distal tarsal tunnel syndrome is further divided into entrapment of the terminal branches of the tibial nerve, specifically the medial plantar nerve and lateral plantar nerve otherwise known as jogger’s foot and Baxter nerve respectively. Patient’s with jogger’s foot report pain along the medial plantar side of the foot that is induced with exercise. The pain can radiate to the bottom of the first, second and third toes and can also radiate up into the inside of the heel and ankle. It’s important for physical examination to occur including examining shoe wear for sources of external compression such as excessive or rigid arch support. Imaging can further assist with diagnosing causative deformities. Again initial treatment is non-surgical management and if these fail surgical release may be considered. Patient’s with Baxter neuropathy, or compression of the lateral plantar nerve, present with pain along the medial plantar aspect of the heel often similar to distribution of pain from plantar fasciitis. Paresthesias and weakness are not typically reported. If diagnosis is unclear, further diagnostic studies may prove to be beneficial. In this case, surgical intervention is often required.

Soleal sling syndrome occurs with the tibial nerve is entrapped in the calf region by a fibrous sling at the origin of the soleus muscle. Patients may report calf pain and have pain that mimics tarsal tunnel syndrome and may even possess a history of failed tarsal tunnel release. Pain with gentle palpation on the calf approximately 9 cm below the flexion crease of the knee will typically generate pain. Weakness may also be present, specifically the flexor hallucis longus. Electrodiagnostic testing can be difficult to perform secondary to the depth of the nerve at this level. Non-surgical management should include modification of activities and discontinued use of restricted clothing or footwear. Anti-inflammatory and nerve-modulating medications may also proved some benefit. If conservative management fails to provide relief then surgical decompression is recommended.

Morton neuroma occurs when there is entrapment of the interdigital nerve most commonly in the third web space and occasionally in the second web space. Patients will present with burning or electric pain and numbness and tingling in the affected webspace. Women are affected more than men. Symptoms are reproduced with direct pressure on the plantar aspect of the foot between the metatarsal heads upon physical examination. Lidocaine injection can also help confirm diagnosis as patient will receive pain relief. Diagnostic tests are usually reserved for abnormal presentations to confirm the diagnosis. Nonsurgical treatment includes fabrication of custom orthoses, metatarsal pads, accommodative footwear and anti-inflammatory medications and injections. If these treatment modalities fail, surgical management may be warranted. One study reviewed advocated a hybrid intraoperative approach in which the nerve is resected if it is found to be thickened otherwise the authors released only the transverse metatarsal ligament and total relief of symptoms was reported in 96-98 per cent of patients.

Superficial peroneal nerve entrapment occurs when the nerve is compressed or entrapped as it pierces the deep fascia because of thickened fascia tunnel, a fascial defect or soft-tissue mass. Most patients will report pain related to activity in the lower outside leg as well as dysesthesias in the dorsum and lateral aspect of the foot. Chronic exertional compartment syndrome should be considered as differential diagnosis. First line of treatment includes removing external factors that may be causing the compression as well as stabilizing any instability that may be tensioning the nerve. Surgery is rarely required.

Anterior tarsal tunnel syndrome occurs when the deep peroneal nerve is entrapped in the anterior tarsal tunnel. Patient’s with entrapment of the lateral branch will report pain along the dorsal foot. Patients with entrapment of the medial nerve branch will report pain and or numbness to the first web space. After thorough physical evaluation, radiologic evaluation can prove critical in the workup as the most common causes of anterior tarsal tunnel syndrome are trauma and impingement of the nerve by bony growths or osteophytes are the talonavicular joint. Non-operative management focuses on reducing external compression, stabilizing ankle laxity and reducing inflammation. Surgical cases should only be reserved for very site specific difficult cases to reduce the risk of scarring from excessive nerve dissection.

Sural nerve entrapment is rare but can occur anywhere in the leg ankle or foot. Patients may report pain, burning, numbness or aching in the back-outside leg, outside part of the ankle or foot. Treatment is dependent on the accurate identification of causative factors and the location of the entrapment. Swelling and underlying instability should be treated first as should any external factors. The authors recommend that if the cause is post traumatic or postoperative then a three to six month period of observation, desentization and neural gliding should occur prior to proceeding to surgery.

Saphenous nerve entrapment is also very rare. Typically it occurs more proximally and patients will present with pain and paresthesias to the foot and ankle. Surgical treatment should be delayed until nonoperative management have failed to provide relief.

In summary, in treatment of entrapment neuropathies of the lower leg, ankle and foot a comprehensive knowledge of relevant anatomy must be possessed followed by thorough physical examination and appropriate treatment. Patient’s will often respond to nonoperative treatment, however, when this fails to provide relief surgical involvement will be considered.

Rotator Cuff Index Measure Predicts Outcome of Nonsurgical Treatment for Rotator Cuff Tears

A recent study aimed to look at whether the outcome of nonoperative treatment of a rotator cuff tear could be predicted on the basis of the patient’s baseline clinical presentation. It additionally wanted to examine whether a successful outcome achieved after three months of treatment in a symptomatic full-thickness rotator cuff tear would be maintained at two years time. Rotator cuff pathology is among the most common causes of shoulder pain. The spectrum of this pathology can span from rotator cuff syndrome all the way to full thickness tearing. Decisions regarding treatment can be complicated as clinical symptoms may not always correlate with extent of damage or degeneration present on imaging. Many surgeons will choose to use an adequate course of nonoperative conservative management lasting at least three months before surgery is considered. However, there is no standard definition of what this “adequate” nonoperative treatment may consist of. Additionally, this may differ from one patient to the next.

The dependent variable used in the prospective cohort study mentioned above, was the outcome of nonoperative treatment classified as either success or failure at the patient’s three-month follow up appointment. Successful treatment was defined that surgery was no longer deemed appropriate by both the patient and the surgeon as the patient demonstrated considerable improvement and was predominantly asymptomatic. If the patient elected to schedule surgery the nonoperative treatment was deemed to have failed. Ten clinical baseline measurements were utilized and examined for their predictive ability. Examples of these baseline measures include age, sex, duration, onset, strength, range of motion, and Rotator Cuff Index Measure. Originally 104 patients met the inclusion and exclusion criteria. Each participant had a documented chronic full-thickness rotator cuff tear and underwent a series of five visits including two with a sports medicine physician, two with a physiotherapist, and one with an orthopedic surgeon. The rehabilitation program included stretching and strengthening exercises. At three months time the patient was scheduled to meet with the orthopedic surgeon whom they had originally been assigned to. After examination, the surgeon classified the outcome of rehabilitation as either a success or failure. The Rotator Cuff Quality-of-Life Index (RC-QOL) instrument was administered at the patient’s first visit, again on arrival at their three-month surgical consultation and then again twenty-four months after their initial baseline assessment. It should be noted that both the sports medicine physician and orthopedic surgeon were blinded to the RC-QOL results.

For analysis, patients were grouped on the basis of outcome of their nonoperative treatment, and the ability to predict this outcome on the basis of the baseline characteristics. Of the original 104 patients ninety-three were analyzed. Seventy five percent of the patients were classified as having a successful outcome at their three-month consultation visit. It was found that the only baseline characteristic that was significant in prediction of success or failure in the analysis was the RC-QOL. Two-year follow up demonstrated that eighty nine percent of the patients maintained their three-month outcome (success or failure). The authors of this article believe these results demonstrate that the RC-QOL can be utilized to determine whether the patient is likely to have a successful or failed outcome in a course of nonoperative treatment.

Calcific Tendonitis is Best Treated Conservatively

Calcific tendonitis occurs when tiny deposits of calcium form on or in a tendon, which then can result in pain and inflammation.  While this can be caused by a number of things, such as poor body mechanics or hypothyroidism, it typically affects people between 30 and 60 years old and more females are affected than males. Frequently these calcium deposits occur on the rotator cuff tendons surrounding the shoulder joint.

The exact reason why these calcium deposits appear is still being argued. The current leading theory is that normal cells in the tendon are replaced by abnormal cells, which is kick started by tendon misuse and abuse. Once the tendon is stressed, the process towards calcific tendonitis is classified into three phases: precalcific state, calcific state, and postcalcific state. This process is often cyclical with the postcalcific state including a return to a normal tendon.

Calcific tendonitis symptoms include primarily pain and a decrease in shoulder motion and strength. X-rays, MRIs, and ultrasounds are often used for diagnosis. Typically the tendonitis is managed without surgery and includes anti-inflammatory medication, physical therapy, and corticosteroid injections. Other conservative and promising treatment options include extracorporeal shock wave therapy and ultrasound-guided needle lavage. Extracorporeal shock wave therapy involves pulses of waves used to blast the calcifications. An ultrasound-guided needle lavage includes a needle inserted adjacent to the calcium deposit with an injection of a saline and anesthetic mixture and a continual flushing of the tissue until the calcification material no longer comes out. However, research for each of these newer treatments has yet to delineate specific effective techniques.

Surgery is reserved for calcific tendonitis that does not respond to conservative methods. Techniques are controversial and have mixed reviews in the literature.

The lead author of a recent review of all available research for treatment and outcomes of people with calcific tendonitis of the rotator cuff concluded that all patients should initially be treated conservatively and informed of the natural progression of the disease. Health providers should emphasize that typically the most pain and tendon inflammation occurs during the re-absorptive state of the calcium deposit, prior to return to fairly normal healthy tendon. Conservative treatment should last three to six months prior to seeking other help. If three months passes without relief, then ultrasound-guided needle lavage is recommended. If this does not work, then at the six-month mark surgery, specifically an arthroscopic decompression is recommended followed by physical therapy.

An Alternate Technique for Total Hip Surgery: The Direct Anterior Approach.

Total hip replacement surgery commonly performed with one of two methods, direct lateral (from the side) or posterior (from the back). In recent years a previously described technique called the Direct Anterior Approach (DAA) has gathered interest because it is a less invasive procedure. This article by Post, et al, is a description of this procedure, indications for it’s use and difficulties commonly seen with this technique.

This procedure was described as long ago as 1881, however with recent improvements in surgical tools and operating tables specifically for the DAA, it has regained popularity. For the DAA a space in the front of the hip, known as the Heuter interval, is utilized to access the hip joint. Using this space allows the surgeon to avoid cutting through muscle or nerves while replacing the hip. This is argued to decrease pain and improve the speed of recovery following a total hip replacement.

Contraindications for DAA included body mass index above forty due to increased abdominal adipose tissue which presents a challenge for this approach. Another consideration is for patients with previous hip surgery as it is not possible to remove plates that are on the side of the hip or femur with this technique.

This procedure does require significant experience from the surgeon, as most studies have found that complication rates decrease after more than one hundred cases. Other small studies have found less pain and better function at six weeks compared to more traditional approach, however there was no difference by six months. A few other retrospecitive studies have demonstrated reduced pain, but it appears that larger randomized studies are needed to determine if there is an advantage to the DAA.

In summary the DAA technique is a viable option, especially with recent improvements in surgical tools for a successful hip replacement. However more long term research needs to be conducted to determine if there is an advantage in long term outcomes. It is also an approach that requires greater surgical experience to avoid common complications, and should be considered when opting for this procedure.

Early Motion and Strengthening Following a Radial Fracture Repair Leads to Decreased Pain and Earlier Return to Function

Lower arm bone fractures are fairly common and are often the result of falling.  When the radius, one of the forearm bones, is badly fractured it is often repaired by inserting a plate with screws to hold all of the bone fragments together. Following the surgery the wrist is placed in a cast for two weeks and strengthening and moving the wrist is not allowed until six to eight weeks after the surgery. However, this protocol for restoring a person’s normal wrist function has now been called into question with the results of a recent research study.  

Authors of this study wondered whether or not it was necessary to place a wrist in the cast for two weeks and hold off on strengthening for so long or if it would lead to faster healing to start the wrist motion and strengthening immediately after surgery.  They took 81 people who under went the same surgery (open reduction and internal fixation with a volar fixed-angle plate) and divided them into two groups.  The first group consisted of 42 people who underwent the standard rehabilitation protocol following the surgery of waiting for two weeks before moving the wrist and another six weeks before beginning strengthening.  The second group was made up of 36 people and underwent an accelerated rehabilitation program which involved beginning gentle passive motion of the wrist and forearm three to five days after surgery with gentle strengthening and active motion beginning at the two week mark. The standard protocol involved all of the same activities of the accelerated four weeks after the accelerated program.  

The authors followed the patient’s recovery for six months after their surgeries.  Results showed that the patients who underwent the accelerated rehabilitation program fared better initially, having less pain and an ability to do more than those undergoing the typical rehabilitation protocol.  At the six month follow up there was not much of a difference. Authors concluded that for a quicker return to normal function, it is recommended to use an accelerated protocol for rehabilitation following a radial head fracture surgery that involves movement immediately after surgery and starts strengthening two weeks after surgery.

Specific Work-Focused Programs Do Not Substantially Alter Return to Work Rate in Patients with Chronic Neck and Back Pain as Compared to Standard Treatments

Neck and lower back pain are among the most prominent disorders that lead to time away from work as well as disability. Studies and models have already been developed focusing on the return-to-work (RTW) process. Multidisciplinary treatment for back pain has been a long standing tradition. In Norway, a recent randomized trial was performed that sought to look at utilizing workplace focused rehabilitation in specialized care versus traditional multidisciplinary treatments with the aim to see if there would be a reduction in the number of days needed before a sustainable RTW among sick-listed patients with chronic neck and low back pain. RTW was defined as the first five-week period after assignment that the patient did not receive sickness benefits, a work assessment allowance pension or a disability pension from the Norwegian Labour and Welfare administration.

The design was a multicenter trial in which sick-listed patients whom were referred to neck and back clinics in Norway were included and followed for one year. Each of the participants were allocated to either the work-focused or control interventions. All patients received a standard clinical examination with imaging evaluated and findings discussed with the patients. Emphasis was placed on removing fear-avoidance beliefs, restoring activity levels and enhancing self-care and coping. Rehabilitation for both groups included sessions of physiotherapy and overall interaction of a multidisciplinary healthcare team. Patients allocated to the work-focused intervention, additionally, had emphasis placed on RTW process. This process included individual appointments with a caseworker in which a RTW schedule was created. The caseworker also assisted members of the work-focused groups with setting up meetings with the employers and helped contact municipal social services if sick-leave compensation was an issue.

Results of the study demonstrated that there was no statistical significant differences found in RTW rate of work-focused group as compared to control intervention group. The median time before RTW was 161 days for the work-focused group and 158 days for the control group. The analyses did demonstrate that 70 per cent of participants in the work-focused group and 75 per cent of participants in the control group returned to work within the first year after inclusion.

Is There an Association of Kyphosis and Diffuse Idiopathic Skeletal Hyperstosis in the Aging Population?

Skeletal changes are common in the aging population. Two of these changes that or prevalent among this population are kyphosis and DISH (diffuse idopathic skeletal hyperstosis) and are found through radiolographical findings. Kyphosis is an increased spinal curvature and the increase prevalence in the aging population can be associated with a decrease in bone density and decrease in back muscle density. Typically kyphosis is measured with a lateral radiograph where spine curvature can be measured using a method known as the Cobb angle measurement. DISH is diagnosed by the presence of ossification in the soft tissue in four continuous segments around the front and side of the thorocolumbar spine with the absence of degenerative disc changes. The cause of DISH is relatively unclear at this time, however, research points out there may be a genetic association hormonal, mechanical, and medication influences on its presence as well as a possible association with diabetes mellitus type 2, obesity, hyperuricemia, and male sex. While it is known that these both are prevalent in the aging population a recent study wanted to examine if there was a possible association between DISH and kyphosis.

The cross-sectional study utilized data for the Health Aging and Body Composition Study (Health ABC) which is an ongoing cohort of participants aged 70-79 years old. They recruited a random sample of age appropriate medicare-eligible Caucasian and African American subjects from the Pittsburgh, PA region. All participants were independent with activities of daily living, could walk one-fourth of a mile and up to 10 steps without rest breaks required. Radiologic assessment with the use of CT scan were utilized to examine for the presence of kyphosis and DISH. They used data from 1172 subject participants. CT scans were studied by two different musculoskeletal radiologists in assessment of DISH for reliable findings. Among participants 152 subjects were diagnosed with DISH, 101 of the cases were located in the thoracic spine and 51 cases were located in both the thoracic and lumbar regions. Overall findings showed a significant interaction of race and DISH with Cobb angle. The presence of DISH among African Americans was associated with an increase in Cobb angle of 8.9 degrees with 95 per cent confidence interval as compared to those without DISH. Among Caucasians, DISH was not significantly associated with Cobb angle. When the location of DISH was further analyzed it was found that when located in the thoracic spine alone there was a significantly associated increase in Cobb angle in both races. However, when DISH was present in both the thoracic and lumbar spine there was not an associated increase in Cobb angle in either races. Overall, these findings indicate the presence of ossification among the anterior longitudinal ligament may change the structure of the spine and affect spinal curvatures. It was found that further research would be warranted to learn whether the presence of DISH is a predictor of worsening kyphosis over time.

Does early weight bearing improve outcomes for non surgical treatment of Achilles tendon rupture?

Non surgical treatment of Achilles tendon rupture has been shown to be equally effective to surgery. However, the best treatment protocol is still unclear, especially the role that early weight bearing bears on recovery. It has been hypothesized that early weight bearing can improve the tendon healing and increase the the quality of treatment because it improves the patients ability to function independently.

The purpose of this study was to compare immediate weight bearing with non weight bearing for non surgical treatment of the Achilles tendon. This protocol also included controlled early range of motion exercises for both groups. The results were measured with the Achilles tendon Total Rupture Score (ATRS), strength of heel-rise compared to the uninjured side, duration of sick leave, re-rupture and quality of life during treatment.

Both groups had the exact same eight week treatment protocol except that the experimental group was allowed to begin full weight bearing from day one. The control group was instructed to prevent any weight bearing for the first six weeks, and full weight bearing allowed for the last two weeks of treatment in the walking boot.

The results show that there was no significant difference in the scores between groups for the ATRS at both six and 12 month follow ups. The heel-rise work outcome also did not differ between the groups at the six or 12 month followup. The questionnaire about quality of life during the eight week treatment period showed that immediate weight bearing did significantly increase quality of life.

This report concludes that is it reasonable to recommend immediate weight bearing for patients being treated with non surgical protocol following Achilles tendon rupture. This is based on the fact that this research showed no detrimental effect on the long term outcome and did improve the quality of life during the initial eight weeks.

Screw Type for Hip Fracture Correction Effects Cost Outcomes

Hip fractures are a very prevalent (~150,000 annually) and costly (~ six billion dollars annually) problem in the United States.  Because of the high costs associated with the care and recovery from a hip fracture, the type of implants being used are under scrutiny.  Implant type is traditionally determined by the hip fracture.  If the hip fracture is considered “stable” then a screw is attached external to the bone, called an extramedullary sliding hip screw.  These show favorable outcomes. An “unstable” hip fracture is often fixed using an intramedullary nailing, which is a rod that is driven into the middle of the bone to help hold the fragments together. These intramedullary nails are more costly than the sliding screws used for a stable hip fracture correction.  

Unfortunately, hip fractures are not often straight-forward and the determination of whether the fracture is stable or not and which screw to use is left up to the surgeon. The failure of the screws is foremost on the surgeon’s mind because failure means another surgery and more pain for the patient.  Not unexpectedly, then, when surgeons are faced with the decision of which screw to use with a questionably unstable or stable fracture, they choose the intramedullary nailing screw.

Authors of a recent study were interested if this in fact saved money or if it ended up being a higher bill for the patient. They drew from a large sample of hip surgeries and found that results hinged on the fixation failure rate and the implant cost itself. For a stable hip fracture, the obvious choice of using an extramedullary sliding hip screw proved cost effective.  This also proved cost effective for a questionably stable hip fracture for about 70 per cent of the cases.  They concluded that for stable and questionably stable hip fractures a sliding hip screw is the best choice.

A Closer Look At Bladder Dysfunction In Persons With Lower Spinal Cord Peripheral Nerve Injuries

Cauda Equina Syndrome (CES) is a resulting cluster of issues a person experiences following damage to their nerves that exit the base of the spine in the shape of horse’s tail, hence the latin anatomical name of “cauda equina”. This important bundle of nerves gives sensation and motor supply to the pelvic organs and lower limbs. In addition, the cauda equina extends parasympathetic nerve supply to the bladder. When injured, persons with CES experience many functional problems with their bladder and/or bowels, decreased sensation in their crotch area, or sexual dysfunction.

Dr. Kim and his research collaborators in Cheonan, South Korea at the Department of Rehabilitation Medicine at Dankook University College of Medicine set forth to find what causes bladder dysfunction in persons with CES or lower spinal cord peripheral nerve injuries.

It is well recognized in the medical community that persons with CES will have bladder problems due to the injury to parasympathetic nerve supply to their bladder. This injury creates a subset of problems called “neurogenic bladder” making it difficult or impossible to urinate, or the opposite end of the urination spectrum making the bladder overactive. Dr. Kim’s team was specifically interested in delving into the cause of this hyperactive bladder or detrusor (muscle) overactivity (DOA).

The hyperactive bladder is problematic in 15-31 per cent of persons with cauda equine syndrome, but the mechanism that causes it cannot be explained solely by the level of the injured spinal nerve. The root causes of the variations in neurogenic bladder issues was the basis for this study. They aimed to further the science using clinical tests (think sophisticated measurements on urine output), radiological (like MRI images), and electrophysiology (like a nerve conduction test) on a group of 61 participants with CES and a hyperactive bladder. Discerning the highest level of spinal cord injury on each person was important finding the injury’s specific neurological impacts down the chain of innervated muscles and organs. Then they took it one more step to differentiate an overactive bladder muscle’s (DOA) dysfunctional performance from its inverse-yet-more-commonly-found bladder muscle dysfunction of detrusor underactivity (DUA).

Dr. Kim and his team found that a third of the study subjects had overactive bladders and within that group most (85 per cent) had their highest level of spinal cord injury at or above the 2nd lumbar spine level. The remaining two-thirds of the study subjects had underactive bladders and most (91 per cent) had their highest level of spinal cord injury at or below the 3rd lumbar spine level. Another interesting finding on subjects with overactive bladders was they often had a higher injury at the lowest section of the spinal cord (conus medullaris) a along with the cauda equine injury.

Failed SLAP Repair Management

Typically, arthroscopic repair of SLAP (superior labrum anterior-posterior) shoulder lesions tend to produce good outcomes. However, there is a small amount of patients that continue to have pain, symptoms or suffer further injury after this repair and may seek additional treatment. A recent review wanted to investigate what the research demonstrates in management of patients whom have suffered a failed SLAP repair.

SLAP tears are a detachment of the superior glenoid labrum from anterior to posterior with or without involvement of the biceps head. Substantial variability exists in methods for diagnosis of these tears including use of orthopedic special tests, MRI (magnetic resonance imaging) and MRA (magnetic resonance arthrogram). Initial treatment usually consists of conservative management including physical therapy, anti-inflammatory agents and activity modification. When non-operative management fails, surgery may be indicated based on a variety of factors. As mentioned earlier these surgical outcomes generally fare well. However, if patients continue to have pain or symptoms following repair it’s important that a thorough workup be performed as the cause can be multifactorial. Differential injections into the subacromial and/or glenohumeral region can be utilized for diagnostic or therapeutic workup and physical therapy can be used for ROM (range of motion) and strengthening. According to the authors of this review, if pain and postoperative stiffness do not resolve with nonsurgical measures, this is defined as a failed SLAP repair. They concluded that recurrent injury secondary to return to the precipitating activity, misdiagnosis, and poor healing are the main causes of failed SLAP repair.

Management of failed SLAP repair can be nonsurgical or surgical. The authors of this review emphasize nonsurgical treatment particularly for overhead throwing athlete as satisfactory outcomes associated with revision have not been conclusively proven in the literature. Rotator cuff strengthening, proper throwing mechanics and physical therapy for ROM are emphasized. Surgical outcomes for failed SLAP repair include revision SLAP repair, and biceps tenotomy(long head of the biceps tendon is released from its attachment) or tenodesis (reattachment of the biceps tendon to the humerus) with or without revision SLAP repair. Revision SLAP repair were deemed most appropriate for young (aged <35 years), active patients without obvious pathology of the long head of the biceps tendon. It was shown that revision SLAP repair were inferior to those of primary repair. Biceps tenodesis is deemed most appropriate for middle aged patients, women and younger patients with known pathology of the biceps tendon. In patients over 65 tenotomy was preferred. It was suggested that select patients with failed type II SLAP repairs that biceps tenodesis may provide safe and effective treatment for failed SLAP repair. Otherwise, data reported demonstrates outcomes that surgical management of failed SLAP repairs are inferior to those of primary repair.

Ten-Year Study for Back Pain: Is Strengthening or Flexibility More Helpful?

Low back pain (LBP) is a big problem, with approximately eighty percent of people reporting back pain at some point in their life. This pain can be the cause of much stress, lost function, lost productivity and financial expense. Exercises have been shown in many research articles to be effective for LBP, but it is not clear as to the parameters. This study by Aleksiev looks into some specific exercises to see which are most helpful over a ten-year period, including frequency, intensity and duration. They looked at the long term effect of strengthening versus flexibility as well as the additional effect of abdominal bracing for everyday activities.

This study included six hundred patients with non-specific low back pain randomized into four treatment groups, each with one hundred and fifty participants. One group performed strengthening exercises alone, one group performed flexibility exercises alone, the third group performed strengthening exercises and did abdominal bracing for everyday activities, and the last group did flexibility and abdominal bracing for everyday activities. All the participants were followed for ten years, and were interviewed on a yearly basis about their symptoms. The participants were asked about maximal pain intensity and duration in days during the latest recurrence of pain as well as the number of episodes of pain during the year. They were also asked to report the number of exercises per day, minutes per session and intensity of the exercise sessions.

The exercises for the strength group were a held crunch movement and a back extension with legs and hands behind head, like superman. Each exercise was to be performed at fifty percent of maximum effort and held for three seconds, they were instructed to perform three sets of ten repetitions. The flexibility exercises included flexion stretch for the back muscles and an extension stretch for the abdominals. The stretches were held for ten to twenty seconds, three to five times. For groups who performed the abdominal brace they were all instructed to incorporate bracing into the regular activities. They were instructed to “brace and breathe,” and to initiate this before any whole-body movement or exercise as often as possible. Bracing intensity and duration were self selected.

This research found that both strength and flexibility exercises were equally effective if done daily to decrease pain. In fact, the more frequent the exercises the better the pain relief. Frequency was more important than intensity or length of time exercising. If abdominal bracing was done for daily activities this also significantly decreased the pain reported over the ten-year study, over one and a half times compared to the groups without abdominal bracing. The largest improvement occurred over the first two years and then the pain reducing effect slowly lessened.

The author hypothesizes that the bracing was more beneficial because it automatically increased the frequency of abdominal and back muscle contraction, therefore increasing strength. The groups doing the abdominal bracing also had increased frequency of exercise, possibly due to the fact that doing the abdominal set reminded them that they should do their exercises, which also increased strength gains.

In conclusion, this study presents abdominal bracing as the most effective method when combined with regular exercise to decrease nonspecific LBP for the long term.

How effective are dynamic compression therapies at reducing ankle edema compared to the standard treatment of elevation and ice?

It is widely accepted in trauma care that a fractured ankle will usually require surgical stabilization, as bearing weight and walking on the broken bone(s) is imperative to functional progress. Controlling the swelling or edema that comes secondary to the injury is an important consideration in expediting the surgical intervention and subsequent rehabilitation. Excessive edema can complicate the surgery and healing, as well as increase the risk of wound complications and infection following the surgery.

Manuela Rohner-Spengler, a clinical Physical Therapist and a team of MD/PhDs from the Departments of Rheumatology and Physiotherapy and Trauma Surgery at the Lucerne Cantonal Hospital in Switzerland took interest the optimal pre-operative swelling management techniques to yield the best post-operative outcomes. In an age of improving medical care with more sophisticated equipment, Ms. Rohner-Spengler and her team wanted to know how effective are new dynamic compression therapies like intermittent impulse compression devices, at reducing ankle edema compared to the standard treatment of elevation and ice.

This study followed rigorous design methods using randomized, controlled, single-blinded clinical trials with repeated-measures on each subject. The 58 subjects all had a similar traumatic injury of fracturing one of their ankles. They were randomly assigned into one of three groups; the standard cold pack and elevation (control) group, the compression bandage group (Ace wrapping), or the impulse compression (a pneumatic compression sock) group. The resulting measures from the various treatment groups were analyzed with intention-to-treat principles, meaning all resulting measures were based on the initial treatment grouping assignment and not on the treatments the subjects eventually received.

Each subject had their ankle girth measured with a flexible tape measure using the figure-of-eight method for five consecutive days before and after the surgery, then again at six weeks post-op. Other measurements tracked through the study were degrees of ankle mobility, pain levels, number of days in hospital, Physical Therapy treatment sessions, amounts of medication required, wound-healing measures and functional outcome data using the Foot and Ankle Ability Measure.

This study found significant differences in edema reduction both pre-operatively and post-operatively between the compression bandage group and the ice and elevate (control) group. The pneumatic compression sock group did not make significant reductions in ankle edema. For example, after two days of pre-operative intervention, the median edema reduction was -23 per cent, -5 per cent, and 0 per cent for the compression bandage, control group, and pneumatic compression group respectively. Another interesting difference noted was improved ankle range of motion following the surgery in the control group over the compression bandage and pneumatic ‘impulse’ squeezer sock.

Shortcomings of this study were the impulse compression device had to be used as a ‘stand-alone treatment’ and thus other secondary typical pre or post-operative edema reduction measures like elevation, cold pack application and compression wraps were not used. The study design also could only use single-blind methodology, which reduces its strength and validity, but it is nearly impossible to blind the subject pool as to what type of treatment they were receiving. Do I have a cold pack on my ankle or is that one of those nifty pneumatic ‘impulse’ squeezer socks?

The take-away findings for patients that have an acute ankle trauma are multilayer compression wrapping can be very effective at reducing swelling before and after surgery. Using combinations of cold packs, elevation and compression therapy can thus be inferred to be helpful for reducing pain, improving ankle range of motion and mitigating edema. Implementing compression wraps with stabilization splints/boots in the emergency room, as well as post-operatively could also lead to a more efficient, less painful healing time.

Treatment Options for Upper Arm Bone Fractures

Four to five per cent of all reported fractures are upper arm bone (humerus) fractures, most frequently occurring in the elderly population from falls.  If the fracture is “non-displaced,” or the bone is still aligned after the break, the bone is simply immobilized for a period of healing time.  If the bone is “mal-aligned” or no longer lining up to the point that it can heal itself, then a decision must be made whether to have a surgical correction or to allow the bone to remain the way it is.  A mal-aligned humeral head (the ball part of shoulder joint) poses difficulty for surgical correction because of the numerous angles that must be accounted for at the shoulder joint, all of the muscles that attach and function surrounding it, and because an offset humeral head can pinch structures like nerves and blood vessels traveling by it during arm movements.

Elderly people who are not high functioning and do not have pain can do ok with malunions without corrective surgery. Broadly speaking, higher functioning individuals and the younger population have two surgical choices: to either preserve the joint (keep the humeral head) or to have a shoulder replacement (take off the humeral head and replace it with metal).  This decision is made depending on the individual and type of mal-union present. The surgical goal is to improve a person’s quality of life and restore as much function as possible, but not necessarily return the person to their previous state of function as this often proves too surgically difficult.   

Joint preservation is appropriate when there are two adjacent surfaces on the bone that can be put back together with hardware and there still is good blood supply to the humeral head. It is often challenging to determine what specifically is causing the pain at the site of the mal-union– the poorly healed bone itself, soft tissue (like tendons or muscles), or a boney protuberance.  All of the contributing factors need to be addressed for good outcomes and joint preservation techniques address these.

Joint replacement is appropriate when there is a good chance of humeral head bone death due to a poor blood supply.  Shoulder joint replacements remain complex even for the most skilled surgeons and the jury is still out on what type of shoulder replacement is most appropriate. The three main options are a partial humeral head replacement, a total humeral head replacement with normal anatomical alignment, or a total humeral head replacement with a reverse alignment from anatomical placement.

Researching the use of spinal cord stimulation after failed back surgery

Failed back surgery syndrome (FBSS) is a problematic source of chronic low back pain. This syndrome is estimated to effect between five and forty percent of all patients who have had surgery for low back pain. This chronic pain can often result in long term disability and contributes large costs to the health care system. Even with the rising frequency of spinal surgery, there is no agreed upon best management for FBSS. This article by Shivanand et al seeks to determine if the use of spinal cord stimulation (SCS) can help to control costs and provide pain relief for this syndrome.

Patients with FBSS are typically treated with conventional medical management (CMM) which mostly includes medicines for pain and depression, physical therapy, and psychosocial therapy. Other treatments may include epidural injections, nerve blocks, and home based portable electrical stimulation units (TENS). If these usual courses of treatment continue to fail, the last options are either to perform another back surgery or to implant a spinal cord simulator. Repeat back surgery has poor outcomes ranging from only twenty-two to forty percent success rate. Repeat surgery also increases the risk for complications and is very expensive. Several randomized controlled trials have shown SCS to have superior outcomes for pain relief over CMM and repeat surgery. This article examines the complications and long-term health care costs of SCS compared to repeat surgery in order to increase the body of knowledge to help decide on the most economic and effective treatment for FBSS.

Spinal cord stimulation is the use an electrode implanted into the spinal cord which provides stimulation to the nerves that come from the source of the pain. This electricity changes the impulses of both the excitatory and inhibitory neurotransmitters to effectively block the sensation of pain. Since its inception in the 1960s many innovations such as smaller and more effective electrodes, and better surgical techniques have made SCS an increasingly viable option for treating chronic back pain.

In this study Shivanand et al looked at the MarketScan commercial Claims and Encounters, Medicare Supplemental and Medicare database records from the year 2000 through 2009. These databases contain patient specific information about usage and costs from claims of employers, health plans, government and public organizations. They searched for all cases with a lumbar surgery or an implantation of SCS which was performed for FBSS or postlaminectomy pain syndrome. They found 16,455 patients who fit this criteria, and among this group there were 6,497 patients who had at least two years of continuous records following this procedure. Only a little over two percent of this group underwent the SCS surgery (395 patients) and the remaining patients, over ninety seven percent, had spinal reoperation (16,060 patients).

Some of the interesting data that they found was that the proportion of females undergoing SCS was higher than those that underwent lumbar surgery. Patients who had SCS also had more comorbidites. Patients with Commercial and Medicare insurance were more likely to have a reoperation, but Medicaid patients were more likely to have the SCS. Complications following the procedure were significantly higher for lumbar reoperations at almost twelve per cent versus only five per cent for SCS. Even at the ninety day follow up the reoperation group was two times more likely to be experiencing complications than the SCS group.

Total costs on the health care system were also investigated by this study. They found that lumbar reoperation patients had a longer initial hospital stay, four days versus two days on average for SCS patients, however this increased stay did not result in significant difference in cost of the initial hospital stay. They also found no significant difference in total costs within the two year follow up timeframe. There was no significant difference in the use of prescription medications in either group either.

In conclusion this study has shown that in a large national group of patients there were fewer complications, shorter initial hospital stay, but similar costs in the first two years for SCS compared to reoperation for FBSS. This study was unable to directly monitor outcomes, but it did see that there was no difference in opioid medication use in either group. Considering this positive information the authors suggest that, at a rate of only two and half per cent utilization, SCS is an underused option of treatment for the increasing number of patients with FBSS.

A Closer Look at Hand and Arm Injuries Caused by Farming Accidents

Agricultural injuries to the upper limbs represent up to 70 per cent of all hospitalizations due to farm accidents, occurring mostly in males. Injuries are often debilitating and result in loss of limb or extensive correctional surgeries.  The cause of most accidents have been studied in detail and include lack of attention, complacency, hurriedness, carelessness, removal of safety shields, and not using machinery in the manner it was meant.  The size of the injury depends on the speed and force of the machinery involved, the amount of contact and struggle, and the type of release from the machine. Machines most frequently involved in upper limb farm accidents include tractors, augers, hay balers, combine harvesters and corn pickers. Often, limbs are pulled into a piece of rotary equipment on the machine resulting in complex injuries of soft tissues (nerves, blood vessels, tendons, muscles) and bone, if not complete amputations.  

Because most of the injuries are in rural settings and frequently involve amputation, proper management of amputations should be followed at the first medical clinic prior to transfer to a trauma center.  For instance, an amputated finger should be rinsed in clean water or warm saline mixture, wrapped loosely in gauze and placed in a plastic bag submerged in ice. The stump should be wrapped with gauze with compression and elevation to minimize bleeding. Because of the high amount of contamination from farm equipment, antibiotics should immediately be administered along with a tetanus booster.

Once the patient is in the operating room, the gauze is removed and surgeons have the difficult task of determining the next step:  to attempt to replant the appendage, reconstruct or amputate. This is based on the extent of the injury, available vasculature and nerve damage as well as the basic surgical principles of preventing infection, restoring greatest amount of function and best healing times.  Surgeons are best prepared to make this decision if they have knowledge of the type of farming equipment involved in association to the injury present as well as the risk of infection from this piece of equipment.

Because of the great amount of complexity associated with agricultural upper extremity injuries the optimum treatment is not straightforward. However, with the proper initial trauma treatment, transfer to a surgery center in a timely manner, and treatment by a surgeon familiar with the farm equipment involved outcomes can be more promising with a faster return to work at a greater level of function.

Is Active Rehab After Spinal Stenosis Surgery Effective?

A recent review article has been published looking at active rehabilitation as a tool to improve postoperative results from lumbar spinal stenosis surgery. Spinal stenosis is the narrowing of the spinal canal which can lead to pressure on the spinal cord or nerve roots, resulting in pain in the back and legs. This condition is usually caused by changes related to aging in the disc, lumbar vertebra, and supporting structures. Surgery to relieve this pressure accesses the spine through the back and then the excesses bone, thickened ligaments and degenerative disc tissue is removed to create space. This procedure has been increasingly common due to rising older population and over the age of sixty five spinal stenosis is the most common indication for spinal surgery. In the US Medicare system more than 37,000 decompression procedures were reported for 2007.

Although this surgery is becoming more common, there is quite a bit of variability reported in the outcomes, and many people do not regain good function following this procedure. Studies report functional improvements between fifty-eight and sixty-nine percent, and participant satisfaction ranges greatly from fifteen to eighty-one percent. Due to these suboptimal outcomes there is need for more research about how to improve upon the success rates. This review was undertaken to determine whether active rehabilitation; including education, exercise, behavioral training, neuromuscular training and stabilization training improved outcomes compared to “usual postoperative care.”

Several common databases were searched for randomized controlled trials that compared the effectiveness of active rehabilitation to that of usual care for adults who have undergone primary spinal decompression surgery. The searches resulted in three studies which fit all the criteria for this review. Usual care included limited advice about being active postoperatively to a brief routine of exercises focused primarily on prevention of deep vein thrombosis. Active rehabilitation included group or therapist led exercise programs focused on restoring or improving function. These programs included exercises for stabilization, muscle strengthening and flexibility as well as education about staying active. Success was measured with a disease-specific measures of functional or disability status (such as the Oswestry Disability Index), measures of global health (36-item Short Form Health Survey), and pain severity.

The evidence coming from these three studies indicates that there is moderate evidence to support that active rehabilitation is more effective than usual care. This is true for both short term and long term function and for low back pain. There is also moderate evidence at twelve months post operation that active rehab is more effective than usual care for improving leg pain. This particular study also mentions a few other studies which, although they did not fit the criteria to be included in these results, have also corroborated these findings, indicating that more research is needed in order to find out the timing and content of the rehab for the best outcomes. Some of these other studies also included pre-operative therapy, cognitive-behavioral therapy, and a back-cafe model (guided group exercise, education and support sessions), indicating that further research needs to be done on a more holistic approach including education and finding patient preferences to help improve outcomes for this increasingly common surgical procedure.