PDF - Advances in Clinical and Experimental Medicine

PDF - Advances in Clinical and Experimental Medicine

ORIGINAL PAPERS
Adv Clin Exp Med 2009, 18, 4, 389–399
ISSN 1230−025X
© Copyright by Wroclaw Medical University
RENATA JABŁOŃSKA1, ROBERT ŚLUSARZ1, JOANNA ROSIŃCZUK−TONDERYS2,
WOJCIECH BEUTH3, WALDEMAR CIEMNOCZOŁOWSKI4
Functional Assessment of Patients
with Lumbar Discopathy
Czynnościowa ocena pacjentów z chorobą dyskową kręgosłupa
1
Department of Neurological and Neurosurgical Nursing, Collegium Medicum in Bydgoszcz,
Toruń in the GCM, Poland
2
Department of Diseases of Nervous System, Wrocław Medical Univeristy, Poland
3
Department and Clinic of Neurosurgery and Neurotraumatology, Collegium Medicum GCM in Bydgoszcz,
Toruń, Poland
4
Department of Methodology Scientific Methodology Labor, Medical College in Bydgoszcz, NCU, Toruń,
Poland
Abstract
Background. Disc disease is a complex of changes in the structures that make up the intervertebral disc and spinal
canal. Functional assessment is evaluation of the ability to cope with the activities of everyday life.
Objectives. The aim was to functionally assess patients treated surgically for lumbar discopathy before and after
the intervention.
Material and Methods. The study was conducted in a group of 46 patients qualified for surgery for lumbar dis−
copathy. The Repty Functional Index (RFI, Polish: WFR) was used to gather data.
Results. The respondents showed complete operational autonomy both before and after treatment. Scores ranged
from 85–105 points. RFI increased for sphincter control both in urinating (mean increase from 6.96 to 7.0 points)
and defecating (6.91 to 7.0 points). The index also rose in the category of locomotion (going on foot from 6.61 to
6.74 points). Decreases were noted in personal care and mobility.
Conclusions. Patients with discopathy of the spine show complete independence in carrying out the activities of
everyday life. The functional assessment was somewhat worse at the time of release from the neurosurgical ward
(Adv Clin Exp Med 2009, 18, 4, 389–399).
Key words: discopathy, spine, evaluation, functioning.
Streszczenie
Wprowadzenie. Choroba dyskowa jest zespołem zmian strukturalnych tworzących krążek międzykręgowy i ka−
nał kręgowy. Ocena czynnościowa to umiejętność radzenia sobie z czynnościami dnia codziennego.
Cel pracy. Ocena czynnościowa chorych leczonych operacyjnie z powodu dyskopatii lędźwiowej kręgosłupa
przed i po zabiegu.
Materiał i metody. Badaniami objęto grupę 46 chorych przyjętych na oddział z powodu dyskopatii lędźwiowej,
którzy zostali zakwalifikowani do leczenia operacyjnego. Do zbierania danych wykorzystano Wskaźnik Funkcjo−
nalny „Repty” (WFR).
Wyniki. Respondenci, zarówno przed, jak i po leczeniu operacyjnym wykazują pełną samodzielność; uzyskana
punktacja mieściła się w przedziale 85–105 pkt. WFR zwiększył się w kategorii kontrola zwieraczy, zarówno w od−
dawaniu moczu (średnio z 6,96 pkt. do 7,0 pkt.), jak i w oddawaniu stolca (średnio z 6,91 pkt. do 7,0 pkt.). Wska−
źnik wzrósł również w kategorii lokomocja – w chodzeniu pieszo: z 6,61 pkt. do 6,74 pkt. Spadek średniej punk−
towej odnotowano w samoobsłudze i mobilności.
Wnioski. Pacjenci z chorobą dyskową kręgosłupa wykazują pełną samodzielność w wykonywaniu czynności dnia
codziennego. Ocena czynnościowa badanych jest nieco gorsza po zastosowanym leczeniu operacyjnym, w dniu
wypisu z oddziału (Adv Clin Exp Med 2009, 18, 4, 389–399).
Słowa kluczowe: dyskopatia, kręgosłup, ocena, funkcjonowanie.
390
Disc disease, also called discopathy or damage
to the disc, is a group of structural changes as an
aftereffect of disorders of mutually arranged ele−
ments creating the intervertebral disc and spinal
canal [1–3]. Discopathy is a degenerative disease
of the organ of movement and consists of three
pathogenic factors which can be analyzed in terms
of biomechanics (overload), pathobiology (inflam−
mation), and neurophysiology (nociception) [2].
Everyday mechanical wear and the aging process
continuously influence the destruction of interver−
tebral discs. The process lies in the biomechanical
and tissue decomposition of a disc caused by the
burden of the spine, inborn defects, as well as
spinal damage caused by past disease and injury
[4, 5]. Thus the height of the intervertebral disc
drops, which destabilizes the whole motive seg−
ment and leads to damage of the remaining ele−
ments. Its functional abilities worsen in visibly
significant ways, i.e. elasticity, carrying capacity,
and ability to regenerate [4, 6, 7]. Stimuli that
damage tissues in turn cause inflammation, which
is a complex defensive reactive of the organism.
The hernial process of discopathy causes vertebral
canal invasion and reduces its lumen to various
degrees, particularly on the lateral sides in which
nerve roots run. Roots damaged in this way generate
neuropathic pain, as opposed to receptor pain [8].
Although most people complaining of spinal
pain are successfully cured by conservative meth−
ods, some require surgery; however there is no
consensus regarding treatment [7, 9, 10]. The
assessment of neurological status is fundamental
in deciding the choice of treatment and also the
main criterion defining its effectiveness. Despite
many clinical observations, great advances in
medicine, and experience, spinal pain is common,
persistent, and chronic and tends to recur without
any perceptible cause. It results in a total inability
of the afflicted to perform at work and is also often
the cause of total loss of working ability [11].
According to statistics, 90% of the population of
the USA experience discopathy sometime during
their life. One can assume that the data in other
developed countries are similar [10].
Functional assessment is an evaluation of the
ability to perform the activities of everyday life.
These include the ability to be independent of
other persons in satisfying basic life necessities,
such as moving, nourishing, controlling physio−
logical functions of the organism, and carrying our
hygienic activities [12]. Although they are physi−
cal processes, they also have a psychological
dimension because a deficit of physical efficiency
has an unfavorable impact on mood and quality of
life. Efficient and independent functioning has sig−
R. JABŁOŃSKA et al.
nificant practical and emotional meaning for the
patient and is conducive to a feeling of indepen−
dence [11].
The aim of this study was to conduct function−
al assessments of patients treated surgically for
lumbar discopathy before and after the interven−
tion, i.e. on the day of leaving the hospital ward.
Material and Methods
The examinations were conducted at the
Department of Neurosurgery and Neurotraumato−
logy in the Efficient Therapy Division of J. Biziel
Regional Hospital in Bydgoszcz, Poland. The
examinations were conducted on 46 patients qual−
ified for surgery for lumbar discopathy. Approval
of the Bioethics Committee of the Collegium
Medicum in Bydgoszcz to conduct this study was
obtained.
The subjects were characterized regarding
age, sex, place of residence, education, profession−
al status, and the kind of job they were currently
doing. Table 1 presents these data. In the examina−
tions, the Repty Functional Index (RFI, in Polish:
WFR) was used. The RFI/WFR was introduced by
J. Opara et al. [13] at the Repty Silesian
Rehabilitation Center in the Tarnowskie
Mountains in 1998. It was created as a modifica−
tion of American FIM (Functional Independence
Measure) scale. The RFI, in contrast to the FIM,
does not cover items connected with “social
awareness” (interpersonal contacts, problem solv−
ing, memory) because they do not subject to point
opinion and belong more to the sphere of special
psychological and sociological tests [12].
The RFI is a universal tool which can be suc−
cessfully applied in assessing independence in var−
ious neurological diseases as well as illnesses of
the organ of movement, especially after cerebral
injury or damage to the peripheral nervous system,
diseases of the extrapyramidal system, muscle dis−
eases, spinal pain, arthrosis, and after limb ampu−
tation [13–15]. The examinations were carried out
on the same patient twice: on the day before their
operation as well as on leaving the ward, usually
on the seventh day after surgery.
The arithmetic means of the patients RFI
scores were compared as a measure of the central
tendency of the studied feature in the whole
patient population. Investigation of changes in fea−
tures and possible correlations was conducted on
the basis of the nonparametric Spearman correla−
tion with the use of the Statistica computer pro−
gram. A level of p ≤ 0.05 was accepted as signifi−
cant.
391
Assessment of Patients with Lumbar Discopathy
Table 1. Characteristics of the examined population
Tabela 1. Charakterystyka badanej populacji
Examined feature
(Badana cecha)
Number of people examined
(Liczba zbadanych pacjentów)
%
Age – years
(Wiek – lata)
≤ 40
41–50
> 50
total
18
16
12
46
39.1
34.8
26.1
100.00
Sex
(Płeć)
women
men
total
18
28
46
39.1
60.9
100.0
Education
(Wykształcenie)
basic
vocational
average
high
total
0
23
16
7
46
0.0
50.0
34.8
15.2
100.0
Place of residence – no. inhabitants
(Miejsce zamieszkania – liczba
mieszkańców)
village
town: ≤ 25,000
town: 26,000–100,000
city: > 100,000
total
14
6
10
16
46
30.4
13.0
21.7
34.8
100.0
Job status
(Status zawodowy)
student
active professionally
pension/annuity
pension/annuity + active
unemployed
total
0
32
7
2
5
46
0.0
69.6
15.2
4.3
10.9
100.0
Kind of work
(Rodzaj pracy)
physical labor
mental labor
total
26
12
46
73.9
26.1
100.0
Results
The examinations showed that the respondents
were able to perform independently both before
and after surgery. Their RFI scores ranged from
Table 2. Assessment of functional capacity according to
the RFI scale
Tabela 2. Ocena wydolności funkcjonalnej badanych wg
skali WFR
RFI/WFR Score
(Ocena RFI/WFR)
Before operation
(Przed operacją)
After operation
(Po operacji)
n
n
%
%
85
87
89
91
93
95
97
99
101
103
105
0
1
2
0
1
2
3
3
7
9
18
0
2.2
4.3
0
2.2
4.3
6.5
6.5
15.2
19.6
39.1
2
0
1
2
3
4
0
4
4
5
21
4.3
0
2.2
4.3
6.5
8.7
0.0
8.7
8.7
10.9
45.7
Total
(Razem)
46
100.0
46
100.0
85–105 points (Table 2, Fig. 1). The mean ± SD
score before intervention was 101.3 ± 4.713 and
after intervention 100.43 ± 5.868, which means
that the functional assessment after the operation
was a little worse, by 0.9 points (Table 3).
The different categories of the RFI scale were
then subjected to analysis. For personal care, the
first group of functional assessment, the values
decreased from 40.43 to 39.52 points (Table 4,
Fig. 2). This drop was visible in every determinant
of the criterion, although it was most visible for
care of appearance and personal hygiene (from
6.83 points before the operation to 6.57 points
after). Consuming meals caused the least problem
(drop of 0.05 points).
Table 3. Average total scores according to the RFI scale
Tabela 3. Średnia uzyskanych punktów wg skali WFR
N Mean
SD
(Średnia)
Min Max
(Min.) (Maks.)
Before operation 46 101.30
(Przed operacją)
4.713 87
105
After operation
(Po operacji)
5.868 85
105
46 100.43
45
42
39
40
36
44
Care of one’s appearance
and hygiene
(Dbałość o wygląd i higienę)
Bath
(Kąpiel)
Getting dressed
– upper parts of the body
(Ubieranie – górne
części ciała)
Getting dressed
– lower parts of the body
(Ubieranie
– dolne części ciała)
Hygiene
(Toaleta)
95.7
78.3
87.0
84.8
91.3
97.8
2
7
5
5
4
1
4.3
15.2
10.9
10.9
8.7
2.2
%
3
1
2
n
6.5
2.2
4.3
%
n
%
6.91
6.43
6.70
6.61
6.83
6.96
41
33
38
32
37
44
n
89.1
71.7
82.6
69.6
80.4
95.7
%
n
%
n
aver−
age
full
independence
total
dependence
medium
independence
full
independence
help
needed
After operation
(Po operacji)
Before operation
(Przed operacją)
Having meals
(Przyrządzanie posiłków)
RFI/WFR
Tabela 4. Ocena wydolności funkcjonalnej badanych wg WFR – samoobsługa
Table 4. Assessment of functional capacity according to the RFI scale: personal care
8
2
5
11
7
12
n
10.9
23.9
15.2
26.1
17.4
4.3
%
medium
independence
2
1
2
1
n
help
needed
4.3
2.2
4.3
2.2
%
n
%
total
dependence
6.78
6.35
6.61
6.30
6.57
6.91
aver−
age
392
R. JABŁOŃSKA et al.
393
Assessment of Patients with Lumbar Discopathy
44
42
40
38
36
34
32
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
before treatment
log (before treatment)
after treatment
log (after treatment)
Fig. 1. General level of functional capacity according to the RFI scale
Ryc. 1. Poziom ogólny wydolności funkcjonalnej badanych wg skali WFR
44
42
40
38
36
34
32
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
before treatment
log (before treatment )
after treatment
log (after treatment)
Fig. 2. Level of functional capacity according to the RFI scale: personal care
Ryc. 2. Poziom wydolności funkcjonalnej badanych wg skali WFR – samoobsługa
Sphincter control is another category of func−
tional assessment. In this criterion, urinating and
defecating are taken into account. There was some
improvement in both: urinating increased from
6.96 to 7.0 points and defecating from 6.91 to 7.0
points (Table 5, Fig. 3).
The third category of functional assessment
was mobility. Here one can observe a general
decrease from 20.43 points to 20.26 (Table 6, Fig. 4).
The most frequent problem patients had in this
regard was going under a shower or into a bathtub;
one respondent (2.2%) required help in this action
before intervention and two respondents (4.3%)
after intervention.
The results concerning locomotion show that
the mean value for this category rose slightly after
surgery, from 12.65 to 12.78 points (Table 7, Fig. 5).
This category consists of two determinants: walk−
ing and using stairs. The first remained at an
approximately steady level (6.61 points before
surgery and 6.74 after) and the second stayed at
the same level of 6.04 points. In fact, the number
of people with full independence in walking stairs
increased (from 26 to 30) and the number of peo−
ple with moderate independence dropped (from 18
to 11), while two needed help before the operation
and four afterwards. One person was classified as
entirely dependent in this regard after the opera−
tion.
Communication was the last analyzed catego−
ry of functional assessment. The results show
small differences: 97.8% of the respondents
showed independent verbal speech as well as aural
and visual understanding (Table 8, Fig. 6).
The statistical analysis demonstrated that the
functional assessments before and after the applied
95.7
2
1
4.3
2.2
%
n
%
43
38
Sitting on a toilet bowl
(Siadanie na muszli
klozetowej)
Going under the shower
or into a bathtub
(Wejście pod prysznic
albo do wanny)
82.6
93.5
97.8
%
7
3
1
15.2
6.5
2.2
%
1
n
2.2
%
n
%
6.61
6.87
6.96
37
43
43
n
80.4
93.5
93.5
%
n
45
n
100.0
100.0
%
full
independence
46
46
n
medium
independence
aver−
age
6.91
6.96
full
independence
total
dependence
%
After operation
(Po operacji)
help
needed
n
Before operation
(Przed operacją)
Getting up from bed onto
a wheelchair
(Wstawanie z łóżka
na wózek)
RFI/WFR
Tabela 6. Ocena wydolności funkcjonalnej badanych wg skali WFR – mobilność
Table 6. Assessment of functional capacity according to scale the RFI: mobility
44
Defecating
(Oddawanie stolca)
97.8
%
n
45
n
aver−
age
full
independence
total
dependence
medium
independence
full
independence
help
needed
After operation
(Po operacji)
Before operation
(Przed operacją)
Urinating
(Oddawanie moczu)
RFI/WFR
Tabela 5. Ocena wydolności funkcjonalnej badanych wg skali WFR – kontrola zwieraczy
Table 5. Assessment of functional capacity according to the RFI scale: sphincter control
%
7
3
3
n
15.2
6.5
6.5
%
medium
independence
n
medium
independence
2
n
help
needed
n
help
needed
4.3
%
%
%
n
%
total
dependence
n
total
dependence
6.52
6.87
6.87
aver−
age
7.00
7.00
aver−
age
394
R. JABŁOŃSKA et al.
26
Stairs
(Chodzenie po schodach)
56.5
80.4
18
9
39.1
19.6
2
n
4.3
%
n
45
45
Verbal speech
(Mowa)
97.8
97.8
1
1
2.2
2.2
%
n
%
n
%
6.96
6.96
45
45
n
97.8
97.8
%
n
n
%
full
independence
aver−
age
65.2
87.0
medium
independence
30
40
%
full
independence
total
dependence
6.04
6.61
n
After operation
(Po operacji)
help
needed
%
Before operation
(Przed operacją)
Listening or Visual
comprehensive
(Rozumienie ze słuchu)
RFI/WFR
Tabela 8. Ocena wydolności funkcjonalnej badanych wg skali WFR – komunikacja
Table 8. Assessment of functional capacity according to the RFI scale: communication
37
%
n
%
n
aver−
age
full
independence
total
dependence
medium
independence
full
independence
help
needed
After operation
(Po operacji)
Before operation
(Przed operacją)
Walking
(Chodzenie)
RFI/WFR
Tabela 7. Ocena wydolności funkcjonalnej badanych wg skali WFR – lokomocja
Table 7. Assessment of functional capacity according to the RFI scale: locomotion
23.9
13.0
%
1
n
2.2
%
medium
independence
11
6
n
medium
independence
1
n
help
needed
4
n
help
needed
2.2
%
8.7
%
2.2
%
n
%
total
dependence
1
n
total
dependence
6.91
6.96
aver−
age
6.04
6.74
aver−
age
Assessment of Patients with Lumbar Discopathy
395
396
R. JABŁOŃSKA et al.
15
14,5
14
13,5
13
12,5
12
11,5
11
10,5
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
before treatment
log (before treatment)
after treatment
log (after treatment)
Fig. 3. Level of functional capacity according to the RFI scale: sphincter control
Ryc. 3. Poziom wydolności funkcjonalnej badanych wg skali WFR – kontrola zwieraczy
22
21
20
19
18
17
16
15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
before treatment
log (before treatment)
after treatment
log (after treatment)
Fig. 4. Level of functional capacity according to the RFI scale: mobility
Ryc. 4. Poziom wydolności funkcjonalnej badanych wg skali WFR – mobilność
treatment were on the same level. This difference
was not statistically significant (p > 0.05). This
was related to the fact that some of the mean val−
ues of the individual categories of the RFI
increased while others decreased. However, the
average assessments of the whole group before
and after treatment were quite similar.
Discussion
Of the great number of spine ailments, the
broadest and most known group constitutes disco−
genic pain caused by pathology in the area of an
intervertebral disc [16]. The pain, together with
neurological disorders and loss of dexterity, is only
a consequence. Spinal pain caused by a degenera−
tive disease of an intervertebral disc is often found
in young and middle−aged people, who are the
most agile and professionally active. It is a cause
of decreased work efficiency, absence due to sick
leave, and resignation from jobs which require
physical involvement or extensive physical effort.
It is also the reason for early retirement in many
cases or for applying for a disability pension. It
might result in discouragement, apathy, depres−
sion, and even a nervous breakdown [9, 17, 18].
Surgery provides the possibility of treating
spinal pain caused by degenerative disc disease: it
interrupts the cascade of degenerative changes in
the spine, reproduces the correct anatomical rela−
tionships, and retains ability of movement [19, 20].
Current reports indicate significant improvement
in health status after such intervention in 75–96%
of cases, depending on the author [1, 9, 21, 22]. An
essential problem is the quality of functioning with
397
Assessment of Patients with Lumbar Discopathy
15
14
13
12
11
10
9
8
7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
before treatment
log (before treatment)
after treatment
log(after treatment)
Fig. 5. Level of functional capacity according to the RFI scale: locomotion
Ryc. 5. Poziom wydolności funkcjonalnej badanych wg skali WFR – lokomocja
15
14
13
12
11
10
9
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
before treatment
log (before treatment)
after treatment
log (after treatment)
Fig. 6. Level of functional capacity according to the RFI scale: communication
Ryc. 6. Poziom wydolności funkcjonalnej badanych wg skali WFR – komunikacja
disc disease, as the restrictions imposed by the dis−
ease relate to professional, social, cultural, as well
as family life [3].
It seems that only surgery is an essential cor−
relate of better functioning in those who under−
went this sort of treatment. The complex and
changeable clinical picture of those suffering from
discopathy makes it difficult to form an objective
and unambiguous opinion of the results of treat−
ment. Patients referred for surgery show more
pathological neurological symptoms than those
who continue conservative treatment. The indica−
tors of improvement directly after surgery are
greater than in a corresponding period of conserv−
ative treatment. Total retreat of neurological
deficits more often involves patients who have
been operated [9, 23]. Of the factors which influ−
ence the functional assessment of patients with
discopathy, one should mention at least three main
components of the disease: the pain, the degree of
disability, and the deficiency symptoms.
The above examinations showed that the
patients generally demonstrated full independence
both before and after intervention, but that after
the neurosurgical operation this independence was
slightly less. After intervention, improvement in
efficiency was observed in sphincter control and
walking ability. However, there were decreases in
the indicators of personal care activities and
mobility, although these differences were not sta−
tistically significant. On the other hand, according
to Frost [24], the index of functional efficiency
after surgery, i.e. on leaving the hospital, obtained
using the same examination tool, improved from
398
R. JABŁOŃSKA et al.
80.9 points (partial dependence before surgery) to
95.2 points (independence after surgery). Different
authors’ case studies [25, 26] also show that
patients who underwent a neurosurgical operation
revealed improvement in functional efficiency on
leaving the hospital ward. A review of the litera−
ture also permits the conclusion that most patients
present a very high degree of functional inefficien−
cy before surgery [26, 27].
The assessment of patients’ functional effi−
ciency with disc disease is one of the criteria
applied in evaluating treatment results. It is essen−
tial mainly because it adequately predicts the
chances of returning to work; a limitation of
one’s own activity is a factor in one’s inability to
work [11]. Last but not least, it seems one is able
to conduct the assessment after treatment.
The authors concluded that patients with lum−
bar discopathy show full independence in terms of
executing the activities of everyday day. The func−
tional assessment of those who were examined
was a little worse after surgery, i.e. on leaving the
hospital ward.
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Address for correspondence:
Renata Jabłońska
Department of Neurological and Neurosurgical Nursing
Techników 3
85−801 Bydgoszcz
Poland
Tel.: +48 52 585 21 93
E−mail: [email protected]
Conflict of interest: None declared
Received: 25.05.2009
Revised: 27.07.2009
Accepted: 20.08.2009