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Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait—A Preliminary 3D Biomechanical Study

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Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait—A Preliminary 3D Biomechanical Study Hindawi Pain Research and Management Volume 2017, Article ID 3059891, 9 pages https://doi.org/10.1155/2017/3059891 Research Article Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait—A Preliminary 3D Biomechanical Study L. Brugliera,1 A. De Luca,2 S. Corna,1 M. Bertolotto,3 G. A. Checchia,4 M. Cioni,5 P. Capodaglio,1 and C. Lentino2,4 1 Istituto Auxologico Italiano, Unita` di Riabilitazione Osteoarticolare, Ospedale S Giuseppe, Strada Cadorna 90, Piancavallo, Italy 2Laboratorio Analisi del Movimento Ospedale Santa Corona di Pietra Ligure, Viale 25 Aprile 38, 17027 Pietra Ligure, Italy 3Centro Terapia del Dolore e Cure Palliative, Dipartimento di Riabilitazione, Ospedale Santa Corona di Pietra Ligure, Viale 25 Aprile 38, 17027 Pietra Ligure, Italy 4Struttura Complessa Recupero e Rieducazione Funzionale, Ospedale Santa Corona di Pietra Ligure, Viale 25 Aprile 38, 17027 Pietra Ligure, Italy 5Scuola di Specializzazione in Medicina Fisica e Riabilitativa, Dipartimento di Scienze Biomediche e Biotecnologiche, Universita` degli Studi di Catania, Piazza Universita2,95131Catania,Italy` Correspondence should be addressed to P. Capodaglio; [email protected] Received 30 March 2017; Revised 21 June 2017; Accepted 1 August 2017; Published 25 September 2017 Academic Editor: Emily J. Bartley Copyright © 2017 L. Brugliera et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We studied 8 patients with spinal cord stimulation (SCS) devices which had been previously implanted to treat neuropathic chronic pain secondary to Failed Back Surgery Syndrome. The aim of our study was to investigate the effects of SCS on posture and gait by means of clinical scales (Short Form Health Survey-36, Visual Analogue Scale for pain, and Hamilton Depression Rating Scale) and instrumented evaluation with 3D Gait Analysis using a stereophotogrammetric system. The latter was performed with the SCS device turned both OFF and ON. We recorded gait and posture using the Davis protocol and also trunk movement during flexion-extension on the sagittal plane, lateral bending on the frontal plane, and rotation on the transversal plane. During and 30 minutes after the stimulation, not only the clinical scales but also spatial-temporal gait parameters and trunk movements improved significantly. Improvement was not shown under stimulation-OFF conditions. Our preliminary data suggest that SCS hasthe potential to improve posture and gait and to provide a window of pain-free opportunity to optimize rehabilitation interventions. 1. Introduction pharmacologic management of pain, physical therapy, and behavioural intervention, as well as therapeutic procedures Chronic pain of moderate to severe intensity occurs in 19% such as injections, radiofrequency ablation, lysis of adhesions, of adult Europeans, seriously affecting the quality of their spinal cord stimulation, and surgical revisions. Physical ther- social and working lives [1, 2]. The prevalence of neuropathic apy and medication management are the cornerstone of first- chronicpainisestimatedwithin0.9and8%[3,4].Chronic line management of FBSS. When this combined approach is pain has direct consequence on the quality of daily living not effective, neuromodulation therapies, in particular spinal and also a considerable social cost either for the national cord stimulation (SCS), have to be considered. Spinal cord health services or for the employers [2, 5]. Failed Back Surgery stimulation has been established as a cost-effective treatment Syndrome (FBSS) has been defined as “persistent or recurrent for patients with neuropathic back and leg pain [6, 7]. The pain in the back/neck or limbs despite surgery or treatment PROCESS study in 2007 involved 100 patients with FBSS thought likely to relieve pain.” After determining the cause and looked at the effects of adding SCS to usual care in of FBSS, a multidisciplinary approach is preferred, including comparison with usual care alone. The study demonstrated 2 Pain Research and Management better results in terms of pain scores, quality of life, functional been complaining of recurring or persistent leg pain, greater capacity, and patient satisfaction with the addition of SCS. than back pain, despite one or more anatomically successful More recently in the PRECISE Study, Zucco et al. [7] per- back surgeries for the same original pain. formed an observational, multicenter, longitudinal ambispec- The year of implant of the SCS device ranged from 2010 to tivestudyon80patientswithFBSSwithpredominantlegpain 2014. Four different models of SCS device had been implanted refractory to conventional medical treatment and followed in our 8 experimental patients. The patients’ characteristics, them for up to 24 months after SCS. Although total societal the SCS devices and their year of implant, and the scores of costs increased after SCS placement, the authors concluded the clinical scales used in the study are described in Table 1. that SCS implantation would be cost-effective in 80%–85% We studied those patients in the Movement Analysis when adjusting for quality-adjusted life years. This study Research Laboratory of the same hospital. The study has been underscores the continued costs of untreated FBSS on society performed in accordance with the Declaration of Helsinki. as a whole, including loss of productivity, costs associated All subjects provided informed consent to the study approved with disability, emergency room visits, imaging costs, and by the Ethics Committee of the Santa Corona Hospital. costs of medications and hospitalizations. A recent Cochrane review [8] reported a moderate level of evidence of the 2.2. Evaluation. Subjectswereevaluatedwithbothclinical effectivenessofSCSinFBSSpatient. scales and an instrumented-quantitative evaluation in order Beneficial effects of SCS on balance and risk of fall have to evaluate the effects of SCS in terms of perceived physical been reported in a study on 11 subjects [9]. A case report in chronic neuropathic pain secondary to FBSS undergoing functioning, pain, health status, and movement. SCS showed an improvement in lower limb muscle strength 2.3. Clinical Evaluation. Before (T0) and after (T1) the stim- and in the motor performance during gait and a reduction ulation, all of the subjects were asked to fill the Short Form in claudicatio independent from the analgesic effect [10]. The author suggested that the anti-ischemic effect of SCS, which Health Survey-36 (SF-36) (Ware and Sherbourne, 1992 [11]), inducesanincreasedbloodflowandoxygenationofthe rate their perception of pain on the Visual Analogue Scales stimulatedarea,mayhaveaccountedfortheresults. (VAS) [12], and provide a score on the Hamilton Depression A biomechanical study in 2005 [10] addressed the short- Rating Scale (HAM-D) [13]. (1–3 months), medium- (6 months), and long-term (1 year) The SF-36 is a 36-item, patient-reported survey of effects on posture and gait of SCS on untreatable chronic pain patient’s health. SF-36 includes one multi-item scale mea- secondary to polyneuropathy, spinal stenosis, and complex suring each of 8 health concepts: (1) physical functioning; regional pain syndrome. The study was conducted using (2) role limitations because of physical health problems; (3) 3 cinematic sensors applied to the trunk and lower limbs: bodily pain; (4) social functioning; (5) general mental health 1 biaxial accelerometer to the trunk in order to measure (psychological distress and psychological well-being); (6) acceleration of the trunk in the vertical and frontal planes, role limitations because of emotional problems; (7) vitality 1 gyroscope and accelerometer on the thigh to measure (energy/fatigue); and (8) general health perceptions. The 8 angular velocity in the sagittal plane, and 1 gyroscope on scaled scores are the weighted sums of the questions in their thecalftomeasureangularvelocityinthesagittalplane. section. Each scale is directly transformed into a 0–100 scale The data acquired for a 5-day period showed a significant on the assumption that each question carries equal weight. improvement in gait (stride length, velocity, and distance Lower scores evidence more disability. walked) and physical activity levels over time. The authors The Visual Analogue Scale (VAS) consists of a 10 cm concluded that SCS was effective not only in pain relief but straight line with the endpoints defining extreme limits such also in improving patients’ gait and physical activity levels. as“nopainatall”and“painasbadasitcouldbe.”Thepatient The gold standard in human movement studies is represented is asked to mark his pain level on the line between the two by 3D Gait Analysis, whose data yield higher specificity and endpoints. The distance between “no pain at all” and the mark sensibility as compared to the aforementioned investigation then defines the subject’s pain. methods. The hypothesis of our research was that SCS may The HAM-D is a multi-item questionnaire used to pro- have a beneficial effect on posture and gait of FBSS patients. vide an indication of depression and as a guide to evaluate The aim of our study was therefore to verify by means of recovery. The questionnaire is designed for adults and is 3D Gait Analysis whether SCS is able to improve posture and used to rate the severity of their depression by probing gait in FBSS patients. mood, feelings of guilt, suicide
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