Lumbar Spinal Stenosis Care Pathway

9. Treatment Considerations for LSS (with central or lateral stenosis)

 

Report of Findings (ROF) and Informed Consent

The Report of Findings (ROF) and Informed Consent process is crucial to patient care and to the therapeutic relationship. It involves explaining the diagnosis, prognosis, and treatment plan to the patient. This ensures the patient understands their condition and the proposed management strategies and agrees to the treatment plan voluntarily.

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1. Review of Diagnosis and Prognosis:

• Clearly explain the diagnosis, results of examinations and tests, and the expected course of the condition using understandable language and visual aids if necessary.

 

2. Treatment Plan Overview:

• Discuss the recommended treatments and their rationale.

• Explain how each intervention aligns with the patient's goals and preferences.

 

3. Informed Consent:

• Explain the condition: Use clear and simple language to describe the patient's condition and how it affects their health.

• Discuss treatment options: Provide detailed information about each treatment option, including the potential benefits, risks, and alternatives.

• Address questions and concerns:

  1. Encourage the patient to ask questions and discuss any concerns they may have.

  2. Provide thorough and understandable answers to ensure the patient feels comfortable and informed.

• Obtain explicit consent:

  1. Review the diagnosis.

  2. Propose a plan of care that relates to the patient’s condition and circumstances.

  3. Contextualize the potential risks and benefits of the proposed treatments.

  4. Encourage the patient to ask questions or express any concerns they may have. Consider utilizing strategies such as “teach-back” to confirm patient understanding.

  5. Ensure that all questions and concerns are appropriately addressed before proceeding.

  6. Obtain explicit consent from the patient to proceed with the proposed treatment plan.

• Document the consent: Ensure the patient's consent is documented in their clinical record. Concisely record the information provided, questions asked by the patient, and the patient's understanding and agreement to the treatment plan.

• Adhere to jurisdictional standards: Ensure the practitioner is meeting their jurisdiction’s standards of practice for informed consent.

 

Core Interventions: Core for managing LSS and applicable to most patients, focusing on optimizing function and participation in daily life.

 

Education and Reassurance:

• Rationale: Helps patients understand their condition, implement pain management strategies, and actively participate in the rehabilitation process.

• Advantages: Increases patient confidence and engagement in their care.

• Disadvantages: Requires time and effective communication skills.

• Key Points: LSS is a chronic condition that can recur or persist. Clarify pain's biopsychosocial dimensions and set realistic expectations (pain can be associated with significant emotional distress such as anger, anxiety, or depressed mood, or significant functional disability including impacts on one’s activities of daily life, hobbies, and participation in social roles). There is limited evidence of superior education types for improving patient outcomes. Tailor education strategies to individual patient needs and preferences (e.g., written, digital, visual). Regularly engage patients in the educational process and assess their understanding to ensure effective communication and knowledge retention.

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Address Yellow Flags:

• Rationale: Factors (fear of movement, anxiety, depression, and social or occupational stressors) can significantly influence the perception of pain, adherence to treatment, and overall recovery.

• Advantages: Promotes a more comprehensive approach to treatment, promotes active participation, improves recovery outcomes.

• Disadvantages: Requires time and resources; some people may resist addressing psychosocial factors; may require a multidisciplinary approach.

• Key Points: Screen for psychosocial factors using validated tools, such as the Fear-Avoidance Beliefs Questionnaire (FABQ), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Opioid Risk Tool (ORT), or the Pain Catastrophizing Scale (PCS). Educate patients on how these factors influence their pain and recovery, and incorporate cognitive behavioral techniques (CBT) to help them manage fear, anxiety, and negative thoughts. Refer to mental health professionals when necessary, especially for significant distress or mental health disorders. Encourage support from family, friends, and support groups, and maintain open, empathetic communication to regularly discuss concerns and progress. Collaborate with other healthcare providers for an integrated, multidisciplinary approach.

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Maintain Activities of Daily Living:

• Rationale: Prevents deconditioning and promotes recovery.

• Advantages: Maintains function and reduces disability.

• Disadvantages: Patients may need guidance on safe activities.

• Key Points: Encourage normal activities and proper self-care. Use Brief Action Planning for self-management.

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Self-Care:

• Rationale: Supports long-term health.

• Advantages: Empowers patients.

• Disadvantages: May require continuous motivation and support.

• Key Points: Set SMART goals, prioritize a healthy diet, regular physical activity, good sleep habits, stress management, and avoid smoking/substance abuse. Implement ergonomics and behavior changes to reduce strain.

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Engage in Social and Work Activities:

• Rationale: Promotes well-being and independence.

• Advantages: Enhances mental health and maintains conditioning.

• Disadvantages: May be challenging for severe pain cases, risk of symptom exacerbation, requires balanced activity.

• Key Points: Encourage gradual re-engagement. Modify activities to fit current functional levels. Educate on pacing and support workplace accommodations if needed to ensure a safe and productive environment for the individual. Additionally, consider ergonomic adjustments, flexible scheduling, and assistive devices to facilitate work performance while minimizing the risk of exacerbating the condition.

 

Exercise Therapy:

• Rationale: Enhances strength, flexibility, and fitness.

• Advantages: Improves function and reduces pain.

• Disadvantages: Requires regular commitment and proper technique.

• Key Points:

  • Types of exercises: Includes strengthening, flexibility, aerobic, core stabilization, Pilates, mind-body exercises (e.g., yoga, tai chi), and aquatic exercise. There is limited evidence of superior exercise types for improving patient outcomes. Tailor to individual needs and preferences.

  • Psychological considerations: Challenging patients during exercise therapy (beyond psychotherapy) can have psychological implications. Watch for signs of increased anxiety, depression, or distress related to the exercise regimen. Be mindful if the person’s mental health condition worsens despite adherence to the exercise program or if the person expresses a strong aversion or fear of the exercises.

  • Referral threshold: Consider referral to the appropriate provider (physician, psychologist, psychiatrist, mental health professional) when the psychological burden of exercise therapy exceeds the patient’s coping capacity or falls outside of the scope (e.g., person exhibits significant psychological barriers or disorders such as severe anxiety or depression).

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Optional Interventions: Tailored to patient needs and preferences through shared decision-making (SDM). These interventions have varying evidence levels.

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Manual Therapy:

• Rationale: Provides symptom relief and improves mobility.

• Advantages: Immediate pain relief.

• Disadvantages: Effects may be temporary; requires skilled practitioners.

• Key Points: Techniques include mobilization, manipulation, soft tissue techniques, and massage. Adjust based on pain exacerbation Contraindications to spinal manipulation therapy include:

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