Louise White

Bio: Louise White is an academic researcher from University Hospitals Birmingham NHS Foundation Trust. The author has contributed to research in topics: Randomized controlled trial & Evidence-based medicine. The author has an hindex of 7, co-authored 11 publications receiving 127 citations. Previous affiliations of Louise White include University of Birmingham.

A survey of post-operative management for patients following first time lumbar discectomy

Abstract: This study aimed to identify current NHS physiotherapy practice following first time lumbar discectomy in the United Kingdom (UK) in order to inform future research priorities and design. Descriptive survey methodology was utilised employing a postal questionnaire. A total population sample was identified and questionnaires were posted to 87 NHS physiotherapy departments throughout the UK. Participants were senior physiotherapists working with spinal surgery patients. In the inpatient phase, the majority of patients receive physiotherapy. Management focused on mobility and education to facilitate early discharge with most patients being given exercises. However, there was a wide variation in the actual exercises prescribed. There was more variation in the provision of outpatient physiotherapy treatment. Not all patients have access to physiotherapy treatment post discharge in the UK and when treatment was available the content and amount was variable. There is evidence to support rehabilitation classes to assist early improvements in function and return to work but such classes are only available in around half of the centres involved in this study. Regarding the content of exercise classes and individual treatment sessions, a wide range of clinical practice was evident. This study raises many research questions and highlights the need for future research to optimise patient rehabilitation following first time lumbar discectomy.

Survey of current physiotherapy practice for patients undergoing lumbar spinal fusion in the United Kingdom.

Abstract: Study Design. Descriptive survey methodology employed a SurveyMonkey online questionnaire. Objective. To evaluate UK National Health Service physiotherapy practice for lumbar spinal fusion surgery. Summary of Background Data. An increasing rate of surgery and high level of patient dis-satisfaction focus attention to rehabilitation of patients undergoing lumbar spinal fusion. Inconclusive, very low-quality evidence for the effectiveness of physiotherapy management after lumbar spinal fusion exists. Best practice, therefore, remains unclear. Limited comparability of outcomes and retrieval of only 2 trials reflected a lack of research and considerable heterogeneity. An evaluation of current practice is required, to inform a future trial to evaluate a best practice physiotherapy intervention. Methods. Eligible participants were all physiotherapists working with patients undergoing spinal fusion. A previous survey and recent systematic review informed questions. Statistical analyses included responder characteristics and preplanned descriptive analyses. Thematic analysis was conducted on open-ended question data. Results. The 83.5% response rate was good. Findings illustrated varied provision relating to assessment and management of patients pre- and postoperatively. Physiotherapists employed limited use of protocols or guidelines, partly attributed to the poor evidence base for this surgery. Scope of practice included exercise, advice, listing for surgery, and ordering investigations. Patient education played an important role. Patient-centered practice was important, although constraints owing to limited resources (staffing, poor evidence, base/lack of protocols) were evident. Conclusion. Current UK pre- and postoperative physiotherapy practice for lumbar spinal fusion is described. It is not clear whether patients who are seen by physiotherapists have improved outcomes, owing to variability of practice, physiotherapy being delivered in a range of locations at a range of times postoperatively, and limited use of outcome measures. The findings support the need for a randomized clinical trial evaluating effectiveness of a best practice physiotherapy management intervention. Conclusion. Level of Evidence: 3

Evaluation of current surgeon practice for patients undergoing lumbar spinal fusion surgery in the United Kingdom.

Abstract: AIM: To ascertain current surgeon practice in the United Kingdom National Health Service for the management of patients undergoing lumbar spinal fusion surgery. METHODS: Descriptive survey methodology utilised an online questionnaire administered through SurveyMonkey. Eligible participants were all surgeons currently carrying out lumbar spinal fusion surgery in the National Health Service. Two previous surveys and a recent systematic review informed questions. Statistical analyses included responder characteristics and pre-planned descriptive analyses. Open question data were interpreted using thematic analysis. RESULTS: The response rate was 73.8%. Most surgeons (84%) were orthopaedic surgeons. Range of surgeon experience (1-15 years), number of operations performed in the previous 12 mo (4-250), and range of information used to predict outcome was broad. There was some consistency of practice: most patients were seen preoperatively; all surgeons ensured patients are mobile within 3 d of surgery; and there was agreement for the value of post-operative physiotherapy. However, there was considerable variability of practice: variability of protocols, duration of hospital stay, use of discharge criteria, frequency and timing of outpatient follow up, use of written patient information and outcome measures. Much variability was explained through patient-centred care, for example, 62% surgeons tailored functional advice to individual patients. CONCLUSION: Current United Kingdom surgeon practice for lumbar spinal fusion is described. The surgical procedure and patient population is diverse, and it is therefore understandable that management varies. It is evident that care should be patient-centred. However with high costs and documented patient dissatisfaction it is important that further research evaluates optimal management.

Patient and physiotherapist perceptions of rehabilitation following primary lumbar discectomy: a qualitative focus group study embedded within an external pilot and feasibility trial.

Abstract: Objective To evaluate patients’ and physiotherapists’ perceptions, preferences and feelings about rehabilitation following lumbar discectomy surgery. Design A qualitative focus group study, informed from the theoretical perspective of phenomenology, of patients’ and physiotherapists’ experiences of rehabilitation following lumbar discectomy was conducted. The focus groups were used to explore patients’ and physiotherapists’ perceptions and their preferences and feelings about different approaches to rehabilitation. The focus groups were facilitated and observed by experienced researchers and were informed by a topic guide that had been piloted previously. Setting The study was embedded within an external pilot and feasibility trial that randomised patients across two secondary care spinal surgery sites in the UK to receive either 1:1 physiotherapy and leaflet or leaflet-only interventions. Participants Five focus groups took place between April and July 2014. A framework analysis of thematic coding (deductive and inductive components) by two researchers captured identified themes common to both patients and physiotherapists. Data from three focus groups with patients and carers (n=11) and two with physiotherapists (n=15) contributed to the analytic framework. Results Emerging themes included: the value of patient leaflets with or without physiotherapy interventions; the importance of self-motivation in the recovery pathway; benefits of group physiotherapy for some patient groups and patient preference influencing rehabilitation. Conclusion Patients and physiotherapists perceived the study patient leaflet and 1:1 physiotherapy interventions as high quality and valuable. Patients’ personal priorities, for example, their need to return to work, influenced their preferences for rehabilitation interventions following surgery.

Physiotherapy Post Lumbar Discectomy: Prospective Feasibility and Pilot Randomised Controlled Trial.

Abstract: Objectives To evaluate: acceptability and feasibility of trial procedures; distribution of scores on the Roland Morris Disability Questionnaire (RMDQ, planned primary outcome); and efficient working of trial components. Design and Setting A feasibility and external pilot randomised controlled trial (ISRCTN33808269, assigned 10/12/2012) was conducted across 2 UK secondary care outpatient physiotherapy departments associated with regional spinal surgery centres. Participants Consecutive consenting patients aged >18 years; post primary, single level, lumbar discectomy. Interventions Participants were randomised to either 1:1 physiotherapy outpatient management including patient leaflet, or patient leaflet alone. Main Outcome Measures Blinded assessments were made at 4 weeks post surgery (baseline) and 12 weeks post baseline (proposed primary end point). Secondary outcomes included: Global Perceived Effect, back/leg pain, straight leg raise, return to work/function, quality of life, fear avoidance, range of movement, medication, re-operation. Results At discharge, 110 (44%) eligible patients gave consent to be contacted. 59 (54%) patients were recruited. Loss to follow up was 39% at 12 weeks, with one site contributing 83% losses. Mean (SD) RMDQ was 10.07 (5.58) leaflet and 10.52 (5.94) physiotherapy/leaflet at baseline; and 5.37 (4.91) leaflet and 5.53 (4.49) physiotherapy/leaflet at 12 weeks. 5.1% zero scores at 12 weeks illustrated no floor effect. Sensitivity to change was assessed at 12 weeks with mean (SD) change -4.53 (6.41), 95%CI -7.61 to -1.44 for leaflet; and -6.18 (5.59), 95%CI -9.01 to -3.30 for physiotherapy/leaflet. RMDQ mean difference (95%CI) between change from baseline to twelve weeks was 1.65(-2.46 to 5.75). Mean difference (95%CI) between groups at 12 weeks was -0.16 (-3.36 to 3.04). Participant adherence with treatment was good. No adverse events were reported. Conclusions Both interventions were acceptable, and it is promising that they both demonstrated a trend in reducing disability in this population. A randomised controlled trial, using a different trial design, is needed to ascertain the effectiveness of combining the interventions into a stepped care intervention and comparing to a no intervention arm. Findings will guide design changes for an adequately powered randomised controlled trial, using RMDQ as the primary outcome.

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review.

Abstract: Objectives Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists’ treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews. Design Systematic review. Setting We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with ‘practice patterns’ and ‘physical therapy’ from the earliest record to April 2018. Participants Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion. Primary and secondary outcomes Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes). Results We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits). Conclusions Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended. PROSPERO registration number CRD42018094979.