Update: Rehabilitation after lumbar disc surgery

Rehabilitation after lumbar disc surgery

Studies have shown late post-operative physical disability and residual pain in patients following lumbar disc surgery despite growing evidence of its beneficial effects. Therefore, rehabilitation is required to minimise the late postoperative complications.

Several rehabilitation programmes are available for individuals after lumbar disc surgery.

Cochrane review in 2009 showed that exercise programs starting 4 to 6 weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery 1) 2).


metaanalysis in 2014 showed considerable variation in the content, duration and intensity of the rehabilitation programmes, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed 3).


A Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis in adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level.

Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge.

In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery.

There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year.

Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral 4).

Case series

2017

Twenty-one patients aged 25-65 years undergoing lumbar microdiscectomy were randomly assigned to the rehabilitation group (n = 14) or active control group (n = 7) by simple randomisation. Eight rehabilitation sessions were initiated 2-3 weeks after surgery. Thirty-minute sessions were conducted twice weekly for four weeks. Post-operative physical disability and pain were assessed at baseline and at the two-year follow-up.

Post-operative physical disability improved more in patients who had undergone rehabilitation than in those who had received control care (63% vs. -23%, P< 0.05). Post-operative residual low back and leg pain were alleviated in the treatment group (26% and 57%, respectively), but intensified in the control group (-5% and -8%, respectively).

This study demonstrated the potential of manipulative rehabilitation and importance of post-operative management after lumbar disc surgery. Definitive trials with larger sample sizes are required to confirm the feasibility and potential therapeutic effectiveness of this approach 5).


A study aimeds to investigate (1) motives, motivations and expectations regarding the choice for a specific rehabilitation setting after herniated disc surgery and (2) how rehabilitation-related motivations and expectations are associated with rehabilitation outcome (ability to work, health-related quality of life and satisfaction with rehabilitation) three months after disc surgery.

The longitudinal cohort study refers to 452 disc surgery patients participating in a subsequent rehabilitation. Baseline interviews took part during acute hospital stay (pre-rehabilitation), follow-up interviews three months later (post-rehabilitation). Binary logistic regression and multiple linear regression analyses were applied.

(1) Motives, motivations and expectations: Inpatient rehabilitation (IPR) patients stated “less effort/stress” (40.9%), more “relaxation and recreation” (39.1%) and greater “intensity of care and treatment” (37.0%) regarding their setting preference, whereas outpatient rehabilitation (OPR) patients indicated “family reasons” (45.3%), the wish for “staying in familiar environment” (35.9%) as well as “job-related reasons” (11.7%) as most relevant. IPR patients showed significantly higher motivation/expectation scores regarding regeneration (p < .001), health (p < .05), coping (p < .001), retirement/job (p < .01), psychological burden (p < .05) and physical burden (p < .001) compared to OPR patients. (2) Associations with rehabilitation outcome: Besides other factors (e.g. age, gender and educational level) rehabilitation-related motivations/expectations were significantly associated with rehabilitation outcome measures. For example, patients with less motivations/expectations to achieve improvements regarding “physical burden” showed a better health-related quality of life (p < .01) three months after disc surgery. Less motivations/expectations to achieve improvements regarding “psychological burden” was linked to a better mental health status (p < .001) and a greater satisfaction with rehabilitation (OR = .806; p < .05).

Rehabilitation-related motivations and expectations differed substantially between IPR and OPR patients before rehabilitation and were significantly associated with rehabilitation outcome. Taking motivational and expectation-related aspects into account may help to improve allocation procedures for different rehabilitation settings and may improve rehabilitation success 6).

2016

Twenty-one patients aged 25-69 years who underwent lumbar microdiscectomy were randomised to either the manipulative rehabilitation treatment group or the active control group. Rehabilitation was initiated 2-3 weeks after surgery, twice a week for 4 weeks. Each session was for 30 minutes. Primary outcomes were the Roland-Morris disability questionnaire and the visual analogue pain scale. Outcome measures were assessed at baseline and post-intervention.

Early post-operative physical disability was improved with a 55% reduction by early individualised manipulative rehabilitation, compared to that of control care with a 5% increase. Early post-operative residual leg pain decreased with rehabilitation (55%) and control care (9%).

This pilot study supports the feasibility of a future definitive randomised control trial and indicates this type of rehabilitation may be an important option for post-operative management after spinal surgery 7).

References

1)

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD003007. doi: 10.1002/14651858.CD003007.pub2. Review. Update in: Cochrane Database Syst Rev. 2014;3:CD003007. PubMed PMID: 18843637.
2)

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery: an update Cochrane review. Spine (Phila Pa 1976). 2009 Aug 1;34(17):1839-48. doi: 10.1097/BRS.0b013e3181abbfdf. Review. PubMed PMID: 19602996.
3)

Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2014 Mar 14;(3):CD003007. doi: 10.1002/14651858.CD003007.pub3. Review. PubMed PMID: 24627325.
4)

Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW. Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. J Physiother. 2017 Jul;63(3):144-153. doi: 10.1016/j.jphys.2017.05.016. Epub 2017 Jun 28. PubMed PMID: 28668558.
5)

Kim BJ, Kim T, Ahn J, Cho H, Kim D, Yoon B. Manipulative rehabilitation applied soon after lumbar disc surgery improves late post-operative functional disability: A preliminary 2-year follow-up study. J Back Musculoskelet Rehabil. 2017 May 5. doi: 10.3233/BMR-169546. [Epub ahead of print] PubMed PMID: 28505954.
6)

Löbner M, Stein J, Luppa M, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, Angermeyer MC, König HH, Riedel-Heller SG. Choosing the right rehabilitation setting after herniated disc surgery: Motives, motivations and expectations from the patients’ perspective. PLoS One. 2017 Aug 22;12(8):e0183698. doi: 10.1371/journal.pone.0183698. eCollection 2017. PubMed PMID: 28829828.
7)

Kim BJ, Ahn J, Cho H, Kim D, Kim T, Yoon B. Early individualised manipulative rehabilitation following lumbar open laser microdiscectomy improves early post-operative functional disability: A randomized, controlled pilot study. J Back Musculoskelet Rehabil. 2016;29(1):23-9. doi: 10.3233/BMR-150591. PubMed PMID: 25792303.

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