Research – Treatment of Advanced Osteoarthritis, Spinal Stenosis and Functional Neurological Disorder

AAT Matter – Access

Applicant (54 year old woman) is seeking Access and has diagnoses of:

Advanced Osteoarthritis (Left Hip)
Spinal Stenosis
Functional Neurological Disorder

What are the known available and appropriate evidence based clinical, medical or other treatments/interventions for each impairment listed above?

Date: September 16, 2020

Requester: Naomi redacted: s22(1)(a)(ii) - irrele (Senior Technical Advisor – TAB/AAT)

Researcher: Craig redacted: s22(1)(a)(ii) - ir (Tactical Research Advisor – TAB/AAT)

Please note:

The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

Contents

Related TAB Research …………………………………………………………………………………………………………….. 2

Summary ………………………………………………………………………………………………………………………………. 2

Definitions …………………………………………………………………………………………………………………………….. 3

Advanced Osteoarthritis (Left Hip) ……………………………………………………………………………………….. 3

Spinal Stenosis …………………………………………………………………………………………………………………… 3

Functional Neurological Disorder …………………………………………………………………………………………. 3

Treatment …………………………………………………………………………………………………………………………….. 4

Advanced Osteoarthritis (Left Hip) ……………………………………………………………………………………….. 4

 Physical Activity/Exercise ................................................................................................................ 5

Weight Management ...................................................................................................................... 5

Medications .................................................................................................................................... 5

Spinal Stenosis …………………………………………………………………………………………………………………… 6

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Medication

Medication …………………………………………………………………………………………………………………….. 6

Physiotherapy

Physiotherapy ………………………………………………………………………………………………………………… 6

Steroid Injections

Steroid Injections ……………………………………………………………………………………………………………. 6

Laminectomy Surgery

Laminectomy Surgery ……………………………………………………………………………………………………… 7

Functional Neurological Disorder (FND)

Functional Neurological Disorder (FND) ………………………………………………………………………………… 7

Neuro-psychiatry & Neuro-psychology

Neuro-psychiatry & Neuro-psychology ………………………………………………………………………………. 8

Physical therapy

Physical therapy ……………………………………………………………………………………………………………… 8

Occupational therapy

Occupational therapy ………………………………………………………………………………………………………. 8

Medications

Medications …………………………………………………………………………………………………………………… 8

References

References ……………………………………………………………………………………………………………………………. 9

NED19/326570: RES HWB Functional Neurological Disorder & CRPS 2019/0060 ADO283 (Research to assist Assessors from NAWM with their decisions for access requests relating to these specific conditions).

Summary

Research indicates that all three conditions are best treated by a multi-disciplinary approach.

Treatment for Advanced Osteoarthritis (Left Hip)

Multi-disciplinary approach is taken with treatment which includes physical activity, weight management, medication, and nondrug pain relief techniques to control pain and complementary and alternative therapies. Australian GPs generally demonstrate a conservative approach, where non-pharmacological interventions were not given the importance suggested by clinical practice guidelines.

Treatment for Spinal Stenosis

Multi-disciplinary approach to treatment which may include medication, physiotherapy, steroids injections, and laminectomy surgery as a last resort (where clinical treatment fails or neurological symptoms worsen).

Treatment for Functional Neurological Disorder

Comprehensive multi-disciplinary team approach involving neurology, neuro-psychiatry, physical therapy, occupational therapy, and Neuro-psychology.

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Definitions

Advanced Osteoarthritis (Left Hip)

Osteoarthritis (AO) is the most common form of arthritis. It occurs when the protective cartilage that cushions the ends of your bones wears down over time. Although osteoarthritis can damage any joint, the disorder most commonly affects joints in hands, knees, hips and spine. [1] Advanced and terminal stage hip OA causes severe restriction of hip range of motion and hip pain. [2]

Spinal Stenosis

Spinal stenosis, or spinal canal stenosis, is a narrowing of the canal in which the spinal cord sits. The arrowing can put pressure on the nerves in the back, which can cause pain and weakness in the arms or legs.

Spinal stenosis is usually caused by arthritis. Some people are born with a narrowed spinal canal, which puts them at greater risk. Spinal stenosis can happen after a disc prolapse (a ‘slipped disc’, or a problem with the spongy discs between the bones of the spine).

Spinal stenosis can also be caused when a thickened ligament bulges into the spinal cord, by a tumour, or by an injury to the back.

The most common form of spinal stenosis is in the lower back (called a lumbar stenosis). It can also happen at the top of the spine (called a cervical stenosis). [3]

Functional Neurological Disorder

Functional neurologic disorders is a newer and broader term that includes what some people call conversion disorder. It feature nervous system (neurological) symptoms that can’t be explained by a neurological disease or other medical condition. However, the symptoms are real and cause significant distress or problems functioning.

Signs and symptoms vary, depending on the type of functional neurologic disorder, and may include specific patterns. Typically these disorders affect movement of the senses, such as the ability to walk, swallow, see or hear. Symptoms can vary in severity and may come and go or be persistent. However, the patient can’t intentionally produce or control the symptoms.

The cause of functional neurologic disorders is unknown. The condition may be triggered by a neurological disorder or by a reaction to stress or psychological or physical trauma, but that’s not always the case. Functional neurologic disorders are related to how the brain functions, rather than damage to the brain’s structure (such as from a stroke, multiple sclerosis, infection or injury). [4]

Treatment

Advanced Osteoarthritis (Left Hip)

It appears a multi-disciplinary approach is taken with treatment. The Australian Institute of Health and Welfare (AIHW) suggests that at present, there is no cure for osteoarthritis (OA) and the disease is long-term and progressive. [5] The Institute suggests treatment for OA aims to manage symptoms, increase mobility and maximise quality of life. General practitioners (GPs) are usually the first point of contact with the health care system for people with OA and are ideally placed to play the role of care coordinator to ensure treatment continuity. GP management of OA may include assessment and diagnosis, referral to other health services, prescribing medication and providing education about the condition.

Treatment options [5] for OA include:

physical activity
weight management
medication
joint replacement surgery

Other sources [6] also suggest the following inclusions in treatment plans:

Rest and joint care
Use of a Crutches, Canes, and Walkers to take weight off the affected hip
Nondrug pain relief techniques to control pain
Complementary and alternative therapies

It would appear that the severity of the OA would determine the likely treatment protocol. A 2016 study [7] looked at International evidence-based guidelines for the management of patients with hip and knee OA which recommend to start with a combination of non-surgical treatments, and using surgical intervention only if a patient does not respond sufficiently to non-surgical treatment options. Despite the recommendations, there are strong indications that nonsurgical treatments are not optimally used in orthopaedic practice.

In Australia, a 2015 survey study set out to examine opinions about the management of OA by Australian GPs following the release of the Royal Australian College of General Practitioners Guideline for the non-surgical management of hip and knee. The study concluded that Australian GPs generally demonstrated a conservative approach to the treatment of OA, and non-pharmacological interventions were not given the importance that is suggested by clinical practice guidelines. [8]

The Royal Australian College of General Practitioners Guideline for the non-surgical management of hip and knee best practice [9], for long term and advanced stage management are:

Long term management of OA

Best practice management of chronic conditions:

optimal use of medicines
non-pharmacological management

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• care and referral pathways • patient self-management education • patient psychosocial support requirements

Treatment and management in advanced stages of OA

Best practice management to optimise quality of life:

• optimal use of medicines • non-pharmacological management • care and referral pathways • patient self-management education • patient psychosocial support requirements • Carer support and information

Physical Activity/Exercise

Exercise is an important and effective component in both management and prevention of OA. Exercise helps improve symptoms (especially pain and joint stiffness) and quality of life by increasing range of motion (the ability to move joints through their full motion), strengthening muscles around affected joints, assists in weight control and reduces risk of other chronic diseases (e.g. diabetes and cardiovascular disease). Exercise is also beneficial for other comorbidities and overall health. A GP or Exercise Physiologist should be consulted before undertaking an exercise program. [5]

Weight Management

Being overweight increases the risk of developing OA, due to the increased load on weight bearing joints and increased stress on cartilage. Weight management is strongly recommended for people with knee and/or hip OA who are overweight or obese. For people with existing OA and who are overweight or obese, weight loss can help reduce symptoms. Weight loss should be combined with exercise for the greatest benefits. A GP or Dietitian can be consulted to discuss weight loss/management strategies. [5]

Medications

Treatment of OA with medication aims to relieve pain, reduce inflammation and improve functioning and quality of life. Analgesics, or pain medications, are commonly used to manage the pain of OA. Analgesics include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics. For those with hip and/or knee OA requiring pain relief, it may be reasonable to trial the use of paracetamol or NSAIDs for a short period and then discontinue use if it is not effective. Corticosteroid injections may also be recommended for short term pain relief for hip and/or knee OA if appropriate. Opioids are not recommended for the treatment of hip and/or knee OA. [5]

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Spinal Stenosis

Research indicates a multi-disciplinary approach to treatment which may include:

Medication (for pain management)
Physiotherapy (build strength, flexibility and balance)
Steroids injections (reduce pain and inflammation)
Laminectomy surgery (where other treatments don’t work) [10]

Medication

In a 2016 literature review [11], suggest that drug treatment does not offer many possibilities. The indiscriminate and frequent use of anti-inflammatory medications for chronic lumbar pain does not have a proven satisfactory response and may be associated with gastrointestinal and renal complications. Its use should be very restricted and avoided in elderly patients with narrow lumbar spinal canal syndrome.

Simple painkillers, muscle relaxants, and opioids may be of value. They are indicated for treating and controlling the pain but have no effect on the treatment of neurogenic claudication. [11] Gabapentin has been shown to be a safe medication; it may be taken orally and has a positive effect on patients with neurogenic claudication and the sensory alterations, which are very common in this cohort of patients [11]. Corticosteroids are also used indiscriminately. The idea is that there is an inflammatory process associated with the mechanical compression that could benefit from the medication, but this theory was not proven. [11]

Physiotherapy

Physiotherapy, or more broadly rehabilitation is a non-surgical approach. Manual therapy, stretching, and muscular strengthening play an important role, in addition to the exercises. Patients who suffer from canal stenosis have, in addition to pain, a significant muscle loss, which severely limits their activities and progressively worsens their clinical condition, which leads to further impairments. [12] [13]

The recommended activities include manual therapy, strengthening, and walking training, as well as exercises that improves proprioception. In addition, weight loss is important, because obese patients have been described to have a worse prognosis. [14]. Cycling is a very much recommended activity, not only because patients tolerate it well, but it also allows them to improve their conditioning and does not impact other joints that may also be degenerated, such as the hip and the knee. [15]

Steroid Injections

Peridural corticosteroids (Steroid injections) are another type of non-surgical treatment for narrow lumbar spinal canal syndrome, as opposed to oral corticosteroids, which were shown to be ineffective for this condition. [14]

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Peridural corticosteroids have some advantages. There are several possibilities for their administration, with or without radioscopy, as well as several techniques: interlaminar, caudal, and transforaminal. Despite their limited benefits, their use may have lasting efficacy in many patients. [15]

Laminectomy Surgery

Surgical treatment is considered the last resort for patients with treating lumbar canal stenosis. Because surgery is performed in patients over 65 years of age, there is significant morbidity and mortality, which increase with associated diseases and patient age, making it mandatory to assess the risks and benefit of the surgery.

Surgical treatment is indicated when clinical treatment fails or neurological symptoms worsen. There are several different surgical techniques.

The classical technique is laminectomy, performed by an incision along the midline followed decompression, removing up to 50% of facets.
Interspinous spacers have been recently included in the surgical arsenal for canal stenosis, but studies are still under way, and there are no studies yet evaluating for an adequate follow-up period.

For this reason, the actual benefit of this kind of surgery is not yet well established. However, it is known that it does offer some advantages, such as short hospitalization periods and limited bleeding. [16]

Functional Neurological Disorder (FND)

Research indicates that FND is best treated within a comprehensive multi-disciplinary team involving [17] [18]:

Neurology
Neuro-psychiatry
Physical therapy
Occupational therapy and,
Neuro-psychology
Speech pathology
Physiotherapists

Patients with physical symptoms (gait disturbance, weakness, paralysis, dystonia, etc.) will often need physical treatment. Allied health professionals including: speech pathologist, occupational therapists and physiotherapists then becomes integral to the patient’s recovery process. [18]

Patients who have early access to an FND specialised multi-disciplinary treatment program with specialist FND knowledge, have the best chance of improved outcomes and potential for recovery. When patients were able to access specialised treatment there were noticeable positive benefits. [19]

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Neuro-psychiatry & Neuro-psychology

Around one third of patients with FND have a comorbid psychiatric condition [18]. Some patients experience depression and anxiety as a result of having their functional symptoms. For others, a history of trauma or adverse childhood experiences can make them vulnerable to developing FND. Psychologists and psychiatrists can assist in the management of comorbid mental health conditions and in the treatment of FND. Cognitive behavioural therapy (CBT) is an evidenced based psychological approach for treating FND. This can include exploring the symptoms and identifying behaviours and cognitions (thoughts) that maintain or exacerbate the symptoms to increase the patient’s awareness of their symptoms. A range of CBT strategies can be taught to the patient to assist them manage their FND and mood symptoms to maximise their everyday function. [18]

Physical therapy

Neuro-physiotherapists can offer education, movement retraining and self-management strategies. Recent research has demonstrated marked improvements in functional motor symptoms in patients who work closely with physiotherapists. [18]

Occupational therapy

Occupational therapists are able to build good rapport with patients and help them with self explorations to understand what they can/can’t do, as well as, determining and addressing the specific blockages for their normal everyday functioning. This is done through a wide range of activities and relaxation techniques. [18]

Medications

Generally, pharmacological therapy for FND is avoided when possible. In the clinical practice, their use may not be welcomed by many patients due to psychiatric stigma, perception of addictive and harmful properties, and side effects. Antidepressants have demonstrated benefits even in those who do not have comorbid mental disorders. Tricyclics are helpful in those with insomnia and pain. Serotonin reuptake inhibitors are good for hypersomnia but not so good in pain management. Neuropathic analgesia such as gabapentin or pregabalin are used in chronic pain. Patients are often explained to that they can get better without the tablets but they are worth trying for those who are looking to explore every therapeutic avenue. [18]

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References

Mayo Clinic. Osteoarthritis - Symptoms and causes [Internet]. 2020 [cited 15 September 2020]. Available from: https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925
Teramoto Y, Fukushima K, Koyama T, Ohashi Y, Uchiyama K, Takahira N et al. Impact of Jiggling Exercise as Conservative Treatment for Hip Osteoarthritis: A Report of Two Cases. Case Reports in Orthopedics. 2020;2020:1-5.
Healthdirect.gov.au. Spinal stenosis [Internet]. 2020 [cited 15 September 2020]. Available from: https://www.healthdirect.gov.au/spinal-stenosis
Mayo Clinic. Functional neurologic disorders/conversion disorder - Symptoms and causes [Internet]. 2020 [cited 15 September 2020]. Available from: https://www.mayoclinic.org/diseases-conditions/conversion-disorder/symptoms-causes/syc-20355197
Osteoarthritis, Treatment & management - Australian Institute of Health and Welfare [Internet]. Australian Institute of Health and Welfare. 2020 [cited 15 September 2020]. Available from: https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoarthritis/contents/treatment-management
WebMD. Hip Osteoarthritis (Degenerative Arthritis of the Hip) [Internet]. 2020 [cited 15 September 2020]. Available from: https://www.webmd.com/osteoarthritis/hip-osteoarthritis-degenerative-arthritis-hip
Hofstede S, Marang-van de Mheen P, Vliet Vlieland T, van den Ende C, Nelissen R, van Bodegom-Vos L. Barriers and Facilitators Associated with Non-Surgical Treatment Use for Osteoarthritis Patients in Orthopaedic Practice. PLOS ONE. 2016;11(1):e0147406.
Basedow M, Williams H, Shanahan E, Runciman W, Esterman A. Australian GP management of osteoarthritis following the release of the RACGP guideline for the non-surgical management of hip and knee osteoarthritis. BMC Research Notes. 2015;8(1).
Royal Australian College of General Practitioners, Guideline for the non-surgical management of hip and knee osteoarthritis [Internet]. Racgp.org.au. 2009 [cited 15 September 2020]. shorturl.at/efrR2
Healthdirect.gov.au. Spinal stenosis [Internet]. 2020 [cited 16 September 2020]. Available from: https://www.healthdirect.gov.au/spinal-stenosis
Rodrigues L. Lumbar Spinal Stenosis, Clinical Presentation, Diagnosis, and Treatment. 2016. DOI: 10.5772/63920
Rittemberg JD, Ross AE. Functional rehabilitation for degenerative lumbar spina stenosis. Phys Med Rehabil Clin N Am (14);111–120, 2003.
Whtiman JM. Flyn TW, Frotz JM. Nonsurgical management of patients with lumbar

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spine stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehabil Clin N Am;14(1):77–101, 2003.

Rodrigues LC, Natour J. A double-blind, randomized controlled, prospective trial assessing the effectiveness of oral corticoids in the treatment of symptomatic lumbar canal stenosis. J Negat Results Bioemed;13:13, 2014.
Whitman JM, Flym TW, Chids JD, Wainer RS et al. A comparassion between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine;31(2):2541–2549, 2006.
Zucherman JF, Hsu KY, Hartjen CA, et al. A prospective randomized multicenter study for the treatment of lumbar spinal stenosis with the X stop interspinous implant: 1- year results. Eur Spine J;13:22–31, 2004.
FND Treatment Australia. FND Australia Support Services [Internet]. Fndaus.org.au. 2020 [cited 16 September 2020]. Available from: https://fndaus.org.au/fnd- treatment-australia/
Mater Centre for Neuro Sciences. Functional Neurological Disorder (FND) Learning guide [Internet]. Fndaustralia.com.au. 2020 [cited 16 September 2020]. Available from: https://fndaustralia.com.au/resources/FND-Learning-guide-for-nurses.pdf
Mentalhealthcommission.gov.au. Consumer and Carer Experiences of fnd/Cd in Australia [Internet]. 2019 [cited 16 September 2020]. Available from: https://www.mentalhealthcommission.gov.au/getmedia/8ac49bb8-556e-42dc-b946- a175149fb57d/Consumer-and-Carer-Experiences-of-FND-CD-in-Australia-FND- Support-Services-Inc

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