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

2. 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

3. 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.

4. 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 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 wks.

5. 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 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).

6. 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

7. 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:
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

8. 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:
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

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

10. 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:
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

11. 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):
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)

12. 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):
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)

14. 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):
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.

15. Inclusion Criteria: Exclusion Criteria: Age 18-60 y
January (2):
Inclusion Criteria:
Age 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

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

17. January (2):
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

18. January (2):
TREATMENT GROUPS

19. RATIONALE: Spine surgery can result in atrophy of multifidus.
January (2):
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.

20. January (2):

21. January (2):

22. January (2):
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.

23. 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.

24. 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).

25. 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. 

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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.