Rehabilitation of the Postoperative Spine Julie M. Fritz, PT, PhD, FAPTA Professor, Associate Dean for Research University of Utah Salt Lake City, Utah, USA

Spine Surgery and Post-Op Rehabilitation Increasing rates for many procedures, particular complex surgery in older patients Outcomes are variable Failure rates are reported between 10% - 40% Utilization and content of post-operative rehabilitation are inconsistent. Evidence-base for post-operative rehabilitation strategies is sparse

22 randomized trials included with participants age 18-65 Oosterhuis et al. Rehabilitation After Lumbar Disc Surgery. Cochrane Database of Systematic Reviews. March, 2014 22 randomized trials included with participants age 18-65 Surgeries included discectomy, microdiscectomy, chemonucleolysis active rehabilitation program include exercise, strength and mobility training, physiotherapy and multidisciplinary programs. Programs may consist of individual sessions, group training or education or a combination of these.

Oosterhuis et al. Rehabilitation After Lumbar Disc Surgery Oosterhuis et al. Rehabilitation After Lumbar Disc Surgery. Cochrane Database of Systematic Reviews. March, 2014 Patients who participated in exercise program 4 - 6 wks post- surgery reported slightly less short-term pain and disability than those who received no treatment. Patients who participated in high-intensity exercise programs reported slightly less short-term pain and disability than those in low-intensity exercise programs. Patients in supervised exercise programs reported little or no difference in pain and disability compared with those in home exercise programs. Here it was difficult to draw firm conclusions in the absence of high-quality evidence. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. The evidence does not show whether all patients should be treated after surgery or only those who still have symptoms after 4 - 6 wks.

3 randomized trials included. Surgeries were decompression McGregor AH, et al. Can exercise give better results after spinal surgery for spinal stenosis? Cochrane Database of Systematic Reviews. December, 2013 3 randomized trials included. Surgeries were decompression Each study involved a rehabilitation program 30 - 90 minutes long, provided once or twice weekly, starting 6 to 12 weeks after surgery. Specially designed exercise programs after decompression can help to reduce back pain and improve the ability to carry out everyday tasks. This was true both in the short term (within 6 months of surgery) and over the long term (at 12 months).

2 randomized trials included. Surgeries were decompression Rushton A, et al. Physiotherapy rehabilitation following lumbar spinal fusion: a systematic review and meta-analysis of randomised controlled trials. BMJ Open, 2012;2:e000829 2 randomized trials included. Surgeries were decompression High risk of bias in studies Both trials suggested that intervention might reduce back pain short- (6 months) and long-term (12 months and 2 years) A behavioral intervention might be more beneficial than an exercise intervention

Factorial Randomized Trial Alexsiev et al. Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): A Factorial Randomized Trial to Determine Whether the Functional Outcome of Spinal Surgery Can Be Improved. Spine 2011: 997-1003 388 patients undergoing surgery for lateral nerve root compression or disc prolapse. Factorial Randomized Trial Factor 1: either 6 weeks of rehabilitation or usual care by surgeon Factor 2: Either an Educational Booklet (“Your Back Operation”) or usual advice by surgeon

Rehabilitation Intervention: Alexsiev et al. Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): A Factorial Randomized Trial to Determine Whether the Functional Outcome of Spinal Surgery Can Be Improved. Spine 2011: 997-1003 Rehabilitation Intervention: - Began 6-8 weeks after surgery - 12 standardized 1-hour classes run by a PT (twice weekly) - General aerobic fitness, stretching, stability, strengthening, ergonomic advice, motivation Education Intervention: - Given a copy of booklet at hospital discharge

Key themes derived from literature used to develop booklet Eur Spine J. 2007 Mar; 16(3): 339–346.

Rehabilitation Intervention: Alexsiev et al. Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): A Factorial Randomized Trial to Determine Whether the Functional Outcome of Spinal Surgery Can Be Improved. Spine 2011: 997-1003 Rehabilitation Intervention: Of those allocated to rehabilitation – 41% attended no classes and an additional 16% attended less than half of the sessions. No impact on outcomes except average leg pain Education Intervention: - No impact on outcomes - No interaction effects between treatments

Randomized to 1 of 3 treatment groups: Mannion AH et al. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J 2007:16(8):1101-17. 159 patients with degenerative spine disease (stenosis or disc disease) scheduled for decompression, age > 45 Randomized to 1 of 3 treatment groups: Self management for 12 weeks (advised to be active and exercise) PT with spine stabilization (2 sessions per week for 12 weeks) PT with mixed techniques (2 sessions per week for 12 weeks)

Randomized to 1 of 3 treatment groups: Mannion AH et al. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J 2007:16(8):1101-17. 159 patients with degenerative spine disease (stenosis or disc disease) scheduled for decompression, age > 45 Randomized to 1 of 3 treatment groups: Self management for 12 weeks (advised to be active and exercise) PT with spine stabilization (2 sessions per week for 12 weeks) PT with mixed techniques (2 sessions per week for 12 weeks)

Mannion AH et al. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J 2007:16(8):1101-17. Advising patients to keep active by carrying out the type of physical activities that they most enjoy appears to be just as good as administering a supervised rehabilitation program, and at no cost to the health-care provider.

Inclusion Criteria: Exclusion Criteria: Age 18-60 y January 2015. 49(2):724-731. Inclusion Criteria: Age 18-60 y Imaging confirmation of LDH Scheduled to undergo a one level discectomy/microdiscectomy Exclusion Criteria: Severe peri/postoperative complications Multilevel surgery Other surgical procedures (e.g., fusion) Prior lumbar spine surgery Significant medical comorbidity

Design 10-week follow up 2 weeks post-op 6-month follow up Pre-op baseline 8 weeks – weekly sessions Surgery Rehabilitation

January 2015. 49(2):724-731. TREATMENT GROUPS All patients educated about proper body mechanics, importance of weight management, smoking cessation and stress management. All patients received aerobic exercise, range of motion and trunk strengthening Subjects randomized to specific exercise began specific spine stabilization exercises after 2-3 weeks

January 2015. 49(2):724-731. TREATMENT GROUPS

RATIONALE: Spine surgery can result in atrophy of multifidus. January 2015. 49(2):724-731. RATIONALE: Spine surgery can result in atrophy of multifidus. Poor surgical outcomes have been correlated with the degree of multifidus atrophy. Specific exercises protocols have been found to reduce multifidus atrophy for patients with nonspecific back pain.

January 2015. 49(2):724-731.

January 2015. 49(2):724-731.

January 2015. 49(2):724-731. RESULTS No statistically significant or clinically important between-group differences in disability, pain, global change, sciatica frequency, sciatica bothersomeness or LM muscle function at 10 weeks or 6 months.

Hebert et al. Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables. Eur Spine J 2015:April 4, e-pub ahead of print PURPOSE Explore the relationships between preoperative history and physical examination findings with clinical outcome following lumbar disc surgery METHODS Examined pooled 10-week outcome data. Evaluated univariate and multivariate prediction models.

Clinical Outcomes Baseline and 10-week follow up clinical outcome variables Outcome variable Baseline 10 weeks Change Disability (ODI) (0-100) 42.8(14.6) 13.9(15.6) 28.9(17.7) Leg pain intensity (0-10) 5.6(2.4) 1.2(1.6) 4.4(2.5) LBP intensity (0-10) 4.0(2.4) 1.7(1.9) 2.4(2.2) Values are mean (standard deviation).

Univariate Results Change in disability Change in leg pain intensity   Change in disability Change in leg pain intensity LBP intensity Clinical history variables b Smoking in lifetime 0.47 -0.40 0.26 Current pain medication 12.50 1.97* 0.21 Proportion leg pain (%) 0.28** 0.06** -0.04** Time to surgery (days) 0.03* 0.00 Previous physical therapy -3.64 -1.54* -0.26 Previous injection therapy -4.18 -1.41* -0.27 Bolded estimates are statistically significant at *, p < 0.05; **, p < 0.01 Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. 

Physical examination variables Straight leg raise test 14.88** 2.43**   Change in disability Change in leg pain LBP Physical examination variables Straight leg raise test 14.88** 2.43** 0.65 Cross SLR test 14.31* 1.17 -0.22 LE strength deficit 11.87* 1.54* 0.76 Sensory deficit 12.44* 0.91 0.46 Diminished MSR 14.10** 1.21 -0.11 Centralization -3.27 -0.84 -0.06 Peripheralization 14.76* 1.70 1.63 Prone instability test -8.18 0.55 -0.68 Postural abnormality 13.99* 2.09* 2.32** Aberrant movement -8.46 -0.02 0.60 Bolded estimates are statistically significant at p < 0.10; *, p < 0.05; **, p < 0.01 Physical examination predictors were a positive straight or cross straight leg raise test, diminished LE strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization.

Multivariate Results Adjusted for baseline score and clinical history Disability Adjusted R2 Standardized β Baseline ODW   0.46 P < 0.001 Proportion leg pain 0.19 P = 0.117 Time to surgery (days) 0.35 0.15 P = 0.203 Pain peripheralization 0.39 P = 0.044 0.24

Multivariate Results Adjusted for baseline score and clinical history Back Pain Intensity Adjusted R2 Standardized β Baseline LBP   0.69 P < 0.001 Proportion leg pain 0.46 -0.05 P = 0.660 Pain peripheralization 0.55 P = 0.002 0.33

Multivariate Results Adjusted for baseline score and clinical history Leg Pain Intensity Adjusted R2 Standardized β Baseline leg pain   0.65 P <0.001 Proportion leg pain 0.10 P = 0.369 Previous injection -0.08 P = 0.450 Previous therapy -0.13 P = 0.224 Pain medication 0.61 P = 0.001 0.09 P = 0.351

PERIPHERALIZATION Pain or paresthesia moves distally, away from the spine Paresthesia which was not present is produced Negative predictor of responding to McKenzie directional exercise Positive predictor of responding to mechanical traction

Summary The evidence-base for post-surgical rehabilitation is sparse and equivocal More rigorous studies are needed with well-defined treatments Exploration of targeting rehabilitation to those most likely to benefit Exploration of strategies focused on enhancing self- management skills, self-efficacy, etc.