Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN)

Introduction

Methods

Results

Discussion

Conclusion

Effects of 12 Weeks of Supervised Exercise After Endovascular Treatment: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

This study aimed to assess the effects of supervised exercise training (SET) after percutaneous transluminal angioplasty (PTA) compared with PTA alone on physical function, limb hemodynamics and health-related quality of life in patients with intermittent claudication.

METHODS

Fifty patients who all underwent PTA for intermittent claudication were included in the study. Both groups received usual post-operative care. In addition, the intervention group performed two sessions of hospital-based SET and one home-based exercise session per week for 12 weeks after PTA. The control group did not receive any additional follow-up regarding exercise. The primary outcome was the result of a standardized 6-minute walk test. Secondary outcomes were the treadmill maximum walking distance, treadmill pain-free walking distance, ankle-brachial index, pulse volume recording on the leg and ultrasound scanning. Health-related quality of life was measured using the Short Form 36 and the Claudication Scale.

RESULTS

All measures, except for the Short Form 36 domain of mental health, showed statistically significant positive changes from baseline to 3 months for both groups (p < 0.05). At 3 months, there was a trend towards better results for the intervention group compared with the control group. The median improvement from baseline to 3 months for the 6-minute walk test was 66 m for the intervention group and 45 m for the control group. For maximum walking distance, the median improvement was 251 m for the intervention group and 93 m for the control group.

DISCUSSION

Supervised exercise training after endovascular treatment for patients with intermittent claudication led to greater positive changes after 3 months in the intervention group compared with the control group. The present study's trends of better results with SET after PTA add to the emerging existing evidence, which should encourage physiotherapy practice to offer SET for this patient group.

Twelve-months follow-up of supervised exercise after percutaneous transluminal angioplasty for intermittent claudication: a randomised clinical trial

The aim of this study was to explore the effects during 12 months follow-up of 12 weeks of supervised exercise therapy (SET) after percutaneous transluminal angioplasty (PTA) compared to PTA alone on physical function, limb hemodynamics and health-related quality of life (HRQoL) in patients with intermittent claudication. Fifty patients were randomised to an intervention or a control group. Both groups received usual post-operative care and follow-up measurements at three, six and 12 months after PTA. The intervention group performed 12 weeks of SET after PTA. The control group did not receive any additional follow-up regarding exercise. During the 12 months' follow-up, the members of the intervention group had significantly better walking distance than the control group. The intervention group had a significantly higher HRQoL score in the physical component score of the SF-36, and the domains of physical function, bodily pain and vitality. For limb hemodynamics, there was a non-significant trend towards better results in the intervention group compared to the control group.

CONCLUSION

SET after PTA yielded statistically significantly better results for walking distance and HRQoL in the intervention group than the control group during the 12 months of follow-up.

Buflomedil for intermittent claudication

BACKGROUND

Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease, that develops in a limb during exercise and is relieved with rest. Buflomedil is a vasoactive agent used to treat peripheral vascular disease. However, its clinical efficacy for IC has not yet been critically examined. This is an update of a Cochrane review first published in 2000, and previously updated in 2007 and 2008.

OBJECTIVES

To evaluate the available evidence on the efficacy of buflomedil for IC.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12).

SELECTION CRITERIA

Double-blinded, randomized controlled trials (RCTs) in patients with IC (Fontaine stage II) receiving oral buflomedil compared with placebo. Pain-free walking distance (PFWD) and maximum walking distance (MWD) were analysed by standardized exercise test.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included two RCTs with 127 participants. Both RCTs showed moderate improvements in PFWD for patients on buflomedil. This improvement was statistically significant for both trials (WMD 75.1 m, 95% confidence interval (CI) 20.6 to 129.6; WMD 80.6 m, 95% CI 3.0 to 158.2), the latter being a wholly diabetic population. For both RCTs, MWD gains were statistically significant with wide confidence intervals (WMD 80.7 m, 95% CI 9.4 to 152; WMD 171.4 m, 95% CI 51.3 to 291.5), respectively.

AUTHORS' CONCLUSIONS

There is little evidence available to evaluate the efficacy of buflomedil for IC. Most trials were excluded due to poor quality. The two included trials showed moderately positive results; these are undermined by publication bias since we know of at least another four unpublished, irretrievable, and inconclusive studies.Buflomedil's benefit is small in relation to safety issues and its narrow therapeutic range.

Buflomedil for intermittent claudication

BACKGROUND

Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease, that develops in a limb during exercise and is relieved with rest. Buflomedil is a vasoactive agent used to treat peripheral vascular disease. However, its clinical efficacy for IC has not yet been critically examined.

OBJECTIVES

To evaluate the available evidence on the efficacy of buflomedil for IC.

SEARCH STRATEGY

We searched the specialized trials register of the Cochrane Peripheral Vascular Diseases Review Group (last searched November 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2007), MEDLINE (1966 to November 2007), International Pharmaceutical Abstracts (IPA) (from inception to November 2007), Science Citation Index (from inception to November 2007). We contacted Abbott Laboratories (buflomedil distributor) for controlled clinical trial data and approached authors for additional trial information.

SELECTION CRITERIA

Double-blinded, randomized controlled trials (RCTs) in patients with IC (Fontaine stage II) receiving oral buflomedil compared to placebo. Pain-free walking distance (PFWD) and maximum walking distance (MWD) were analysed by standardized exercise test.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included two RCTS with 127 participants. Both RCTs showed moderate improvements in PFWD for patients on buflomedil. This improvement was statistically significant for both trials (WMD 75.1 m, 95% confidence interval (CI) 20.6 to 129.6; WMD 80.6 m, 95% CI 3.0 to 158.2), the latter being a wholly diabetic population. For both RCTs, MWD gains were statistically significant with wide confidence intervals (WMD 80.7 m, 95% CI 9.4 to 152; WMD 171.4 m, 95% CI 51.3 to 291.5), respectively.

AUTHORS' CONCLUSIONS

There is little evidence available to evaluate the efficacy of buflomedil for IC. Most trials were excluded due to poor quality. The two included trials showed moderately positive results; these are undermined by publication bias since we know of at least another four unpublished, irretrievable, and inconclusive studies.Buflomedil's benefit is small in relation to safety issues and its narrow therapeutic range.

Buflomedil for intermittent claudication

BACKGROUND

Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease, that develops in a limb during exercise and is relieved with rest. Buflomedil is a vasoactive agent used to treat peripheral vascular disease. However, its clinical efficacy for IC has not yet been critically examined.

OBJECTIVES

To evaluate the available evidence on the efficacy of buflomedil for IC.

SEARCH STRATEGY

We searched the specialized trials register of the Cochrane Peripheral Vascular Diseases Review Group (last searched August 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2007), MEDLINE (1966 to August 2007), International Pharmaceutical Abstracts (IPA) (from inception to August 2007), Science Citation Index (from inception to August 2007). We contacted Abbott Laboratories (buflomedil distributor) for controlled clinical trial data and approached authors for additional trial information.

SELECTION CRITERIA

Double-blinded, randomized controlled trials (RCTs) in patients with IC (Fontaine stage II) receiving oral buflomedil compared to placebo. Pain-free walking distance (PFWD) and maximum walking distance (MWD) were analysed by standardized exercise test.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included two RCTS with 127 participants. Both RCTs showed moderate improvements in PFWD for patients on buflomedil. This improvement was statistically significant for both trials (WMD 75.1 m, 95% confidence interval (CI) 20.6 to 129.6; WMD 80.6 m, 95% CI 3.0 to 158.2), the latter being a wholly diabetic population. For both RCTs, MWD gains were statistically significant with wide confidence intervals (WMD 80.7 m, 95% CI 9.4 to 152; WMD 171.4 m, 95% CI 51.3 to 291.5), respectively.

AUTHORS' CONCLUSIONS

There is little evidence available to evaluate the efficacy of buflomedil for IC. Most trials were excluded due to poor quality. The two included trials showed moderately positive results; these are undermined by publication bias since we know of at least another four unpublished, irretrievable, and inconclusive studies.Buflomedil's benefit is small in relation to safety issues and its narrow therapeutic range.

The Australian Vascular Quality of Life Index (AUSVIQUOL): An Improved Clinical Quality of Life Tool for Peripheral Vascular Disease

OBJECTIVES

To validate the Australian Vascular Quality of Life Index (AUSVIQUOL) as a quality of life (QOL) tool appropriate for peripheral vascular disease patients in the clinical setting.

DESIGN

Cross-sectional study.

MATERIALS

The study group consisted of 71 patients with vascular claudication of varying severity attending a tertiary hospital outpatient department.

METHODS

The results of the AUSVIQUOL and Medical Outcomes Short Form Health Survey (SF-36) were compared through factor and regression analyses. A group of 12 patients was then reassessed to compare the reliability and internal consistency of the two indices.

RESULTS

The AUSVIQUOL took less time to complete than the SF-36 (3.27 v 10.79 min; p<0.0001) and fewer patients found the questions confusing (2% v 26%). The AUSVIQUOL was easier to administer and had a higher level of patient acceptance than the SF-36. The regression analysis showed that for each of the domains in the AUSVIQUOL there was a significant correlation with measures in the SF-36 (adjusted R-squared 0.420, 0.480 and 0.331). The AUSVIQUOL demonstrated a good level of internal consistency when compared to the SF-36 (Cronbach's alpha 0.8702 vs 0.6307).

CONCLUSION

In comparison with the SF-36, the AUSVIQUOL is an improved tool for the QOL assessment of patients with peripheral vascular disease in the clinical setting.

AUSTRALIAN VASCULAR QUALITY OF LIFE INDEX (AUSVIQUOL): A PILOT STUDY OF A DISEASE-SPECIFIC QUALITY OF LIFE MEASURE

BACKGROUND

To develop and test a quality of life (QOL) index specific for patients with vascular disease and appropriate for patients with abdominal aortic aneurysm (AAA) in the clinical setting.

METHODS

The questions and domains of the Australian Vascular Quality of Life Index (AUSVIQUOL) were determined by examination of a prospective database for frequency of symptoms and an in-depth interview of a sample population. The validity of the AUSVIQUOL was tested by comparing it with the Medical Outcomes Short Form Health Survey (SF-36) in a study involving 60 patients who underwent endovascular AAA repair and 48 open AAA repair. A subpopulation of 22 patients representative of the two groups was then reassessed using the SF-36 and the AUSVIQUOL, to compare the reliability of the two indices.

RESULTS

Similar domains of the SF-36 and the AUSVIQUOL measured common QOL elements. The correlation between the two indices was moderate; the AUSVIQUOL measured additional disease-specific QOL factors. The AUSVIQUOL showed better reliability than the SF-36 in all domains and statistically better in the physical function domain (P < 0.05).

CONCLUSION

The AUSVIQUOL is an appropriate tool for the QOL assessment of patients with AAA in the clinical setting.

Discrepancies between patient-reported outcomes and clinician-reported outcomes in chronic venous disease, irritable bowel syndrome, and peripheral arterial occlusive disease

OBJECTIVE

To explore the degree of agreement between patient- and clinician-reported outcomes (PROs and CROs, respectively) in three chronic diseases.

METHODS

Respectively, 120, 131, and 61 French general practitioners (GPs) included 291, 307, and 90 patients with chronic venous disease (CVD), irritable bowel syndrome (IBS), and peripheral arterial occlusive disease (PAOD), in a cross-sectional survey. Patients completed a specific Health-Related Quality of Life (QoL) questionnaire (Chronic Venous Insufficiency Questionnaire [CIVIQ], Functional Digestive Disorders Quality of Life [FDDQL], and Claudication Scale [CLAU-S], respectively) and scored their pain (visual analog scale, pain-free walking distance). GPs were concomitantly asked to estimate patients' pain and QoL.

RESULTS

Although correlated (CVD and IBS: Kw = 0.27 and Kw = 0.31, respectively; PAOD: r = 0.64, P < 0.01), pain intensity estimated by GPs was lower than as estimated by patients with CVD and IBS (e.g., 39.0 +/- 24.9 vs. 30.4 +/- 21.0 for IBS), and pain-free walking distance was greater as estimated by GPs than by patients with PAOD. Pain estimated by patients only partially reflected their QoL (r between 0.30 and 0.78; P between 0.02 and <0.01). Global QoL scores estimated by patients and GPs were moderately correlated (Kw between 0.17 and 0.28). GPs underestimated QoL impairment in CVD (global score: 72 +/- 19 vs. 61 +/- 20) and in most dimensions of the IBS questionnaire (in six of eight dimensions), and overestimated QoL impairment in PAOD (54 +/- 21 vs. 66 +/- 23).

CONCLUSIONS

Although correlated, PROs and CROs differed. In addition, their relationship was not consistent across diseases. PROs are therefore essential to take account of all the aspects of diseases.

Health-related quality of life after revascularization for peripheral arterial occlusive disease: long-term follow-up

AIM

This paper reports a study to measure quality of life, before and after revascularization, in patients with intermittent claudication and critical limb ischaemia from a long-term perspective.

BACKGROUND

Patients with peripheral arterial occlusive disease have a number of problems which affect their quality of life and a successful revascularization results in immediate improvements in quality of life. However, knowledge of the durability of the improvements is sparse. Therefore, research on the outcomes of treatment and nursing care should investigate the long-term effects on quality of life and daily activities.

METHODS

A quasi-experimental longitudinal follow-up study was conducted with 80 patients with intermittent claudication and 62 with critical ischaemia. Assessment with the Nottingham Health Profile was made before revascularization and 6 months, 12 months and up to 4 years afterwards. The data were collected between 1995 and 2000.

RESULTS

Quality of life was improved 6 and 12 months after revascularization in patients with intermittent claudication in energy, pain, emotional reactions and physical mobility, while those with critical limb ischaemia also had improvements in pain and sleep. The improvement in pain was particularly evident for both groups and remained significantly improved up to 4 years after revascularization. Patients with critical limb ischaemia, however, deteriorated significantly with regard to physical mobility between 12 months and 4 years. Being a woman and belonging to the critical ischaemia group was significantly associated with high total Nottingham Health Profile score. Thus, patients with intermittent claudication had more durable benefits from revascularization than those with critical limb ischaemia. However, both groups had less pain than at baseline after 4 years.

CONCLUSION

The degree to which quality of life was durable over time seems to depend on the severity of the disease and gender. Patients with critical limb ischaemia were older, had more other diseases and a lower quality of life than patients with intermittent claudication, which confirmed that patients with critical limb ischaemia need more ongoing nursing support to maintain independence in daily life a long time after revascularization.

Management options for patients with intermittent claudication

Peripheral arterial disease is a chronic condition, affecting a significant proportion of the adult population. Intermittent claudication is the earliest clinical manifestation of peripheral arterial disease and the patient's walking distance can be significantly reduced. This restriction can profoundly disrupt activities of living. Treatment options vary according to the level of the disease and co-morbidity of the patient. Current evidence to support risk factor assessment highlights the role of the nurse in encouraging lifestyle modification.

Disease-specific quality of life assessment in intermittent claudication: review

OBJECTIVES

intermittent claudication (IC) is a common condition that has a major impact on the patients' quality of life (QoL). Generic QoL instruments often lack sensitivity to detect small but clinically significant variation in QoL. Disease-specific instruments may overcome this problem. This study aims to review various disease-specific QoL instruments available for use in IC and make recommendations for clinical utilization based on validity, reliability and responsiveness.

METHODS

a detailed literature search and extensive bibliography review of all papers relating to disease-specific QoL and IC.

RESULTS

several disease-specific QoL instruments are available for use in patients with IC. The most notable of these are the Claudication Scale (CLAU-S), Sickness Impact Profile - Intermittent Claudication (SIP(IC)) and the VascuQoL. The Walking Impairment Questionnaire (WIQ) is an objective measure of the patient's walking ability and not a QoL instrument.

CONCLUSION

many of the questionnaires are new and have undergone only a limited validation process. More work is required in this field before any one disease-specific QoL instrument can be recommended for use in patients with IC.

Intermittent claudication: pharmacoeconomic and quality-of-life aspects of treatment

The purpose of this article is to review the literature on the pharmacoeconomics of treatment for intermittent claudication and to discuss the importance of quality-of-life assessment for evaluating treatment strategies. Systemic risk reduction is the primary objective in the treatment of patients with intermittent claudication, as these patients have a high future risk of cardiovascular morbidity and mortality. Modification of cardiovascular risk factors accompanied by antiplatelet therapy is likely to improve overall survival, reduce myocardial infarction and stroke, and will, perhaps, also reduce the risk of ulcers and amputation at acceptable cost-effectiveness ratios. The second goal in the treatment of patients with intermittent claudication is to improve their walking capacity and community-based functional status. Supervised exercise training is the most effective noninvasive intervention to improve walking capacity, but may have elevated indirect costs. Among patients with disabling claudication who are candidates for invasive therapeutic procedures, angioplasty is cost effective in those with femoropopliteal stenosis or occlusion and in those with critical limb ischaemia and a stenosis. For all these therapeutic strategies there is a need to relate the costs to a relevant and comprehensive measure of effectiveness. Quality-of-life evaluation by using questionnaires exploring the specific problems encountered by patients with intermittent claudication in their daily life appear to be the most appropriate tool to evaluate the net result of a treatment. Cost-utility studies by combining pecuniary and quality-of-life evaluations provide information that is extremely useful to patients with intermittent claudication, regulatory authorities, the pharmaceutical industry and healthcare providers.

Developing the Vascular Quality of Life Questionnaire: a new disease-specific quality of life measure for use in lower limb ischemia

AIMS

The purpose of this study was to develop and validate an easily used disease-specific quality of life (QOL) measure for patients with chronic lower limb ischemia and to design an evaluative instrument, responsive to within-subject change, that adds to clinical measures of outcome when comparing treatment options in the management of lower limb ischemia.

METHODS

The first phase consisted of item generation, item reduction, formulating, and pretesting in patients with ischemia. The proportion of patients who selected an item as troublesome and the mean importance they attached to it were combined to give a clinical impact factor. Items with the highest clinical impact factor were used to formulate a new 25-item questionnaire that was then pretested in 20 patients with lower limb ischemia. In the second phase, reliability, validity, and responsiveness of the new questionnaire were assessed in 39 patients with lower limb ischemia who were tested at 0 and 4 weeks. The King's College Hospital's Vascular Quality of Life Questionnaire and the Short-Form 36 were administered at each visit, and treadmill walking distance and ankle/brachial pressure indices were recorded. The new questionnaire's reliability, internal consistency, responsiveness, and validity were determined.

RESULTS

Areas of QOL impairment were consistent through the ranges of disease severity and age, with no apparent differences between the men and women. Therefore, a single questionnaire is applicable to all patients with chronic lower limb ischemia. In stable patients test-retest scores demonstrated a reliability of r more than 0.90. Each item had internal consistency (item-domain Cronbach alpha =.7-.9). The questionnaire was responsive to change, with correlation between change in the questionnaire's total score and both global and clinical indicators of change (P <.001). The questionnaire showed face and construct validity.

CONCLUSIONS

This disease-specific questionnaire is reliable, responsive, valid, and ready for use as an outcome measure in clinical trials. It is sensitive to the concerns of patients with lower limb ischemia, offering a simple method to measure the effect of interventions on their QOL.

[Contraindicated medical references and vasoactive agents in arterial pathology of the lower limbs]

INTRODUCTION

Treatment of arteriopathy of the lower limbs (ALL) with vasoactive drugs must follow French health laws recently introduced in regard to the prescription of unuseful drugs and treatments and the frequency at which some patients resort to specific drugs and treatments. Prescription of vasoactive drugs in ALL requires the existence of functional discomfort. Prescription of only one vasoactive drug is sufficient.

CURRENT KNOWLEDGE AND KEY POINTS

Results of published clinical trials demonstrate the efficacy of vasoactive drugs for the relief of claudication related to arteriopathy. To conform to the rules of the European Drug Agency, treatment with vasoactive drugs which improve the walking distance is recommended as "symptomatic treatment of arterial claudication in ALL". Iloprost is only used in the treatment of permanent ischemia. Prescription of vasoactive drugs is part of a scheme of therapeutic indications that are well known and rigorous. Rules of hygiene and reduction of risk factors are the essential preliminary elements. In the case of arterial claudication due to femoral or distal obliteration, chemical medication is suggested, whereas in the case of iliac lesion, angioplasty should be considered.

FUTURE PROSPECTS AND PROJECTS

Walking is recommended in all the cases; however, usually less than a quarter of all patients will conform to this recommendation. Vasoactive drugs thus find their place in the therapeutic scheme. Evaluation of the efficiency of vasoactive drugs rises above simple measures of the walking distance, rather integrating quality of life and usefulness of the treatment.