Research Review By Dr. Robert Rodine©

Date Posted:

April 2010

Study Title:

Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial

Authors:

Nielsen PR, Jorgensen LD, Dahl B, Pedersen T & Tonnesen H

Author's Affiliations:

Bispebjerg Hospital, Copenhagen, Denmark & the University of Copenhagen.

Publication Information:

Clinical Rehabilitation 2010; 24: 137-148.

Background Information:

The rate of spinal surgeries performed annually is currently increasing throughout the world. This could be due to numerous factors. All efforts must be made to determine the best clinical pathways for surgical patients in order to maximize recovery while minimizing hospital stay times, costs and complication rates.

Prehabilitation is considered to be therapy aimed at increasing a patient’s functional capacity prior to surgery. In theory, if patients are stronger, more functional, more fit and generally healthier prior to their surgery, they are less likely to experience complications and more likely to have a speedy recovery and an accelerated rehabilitation process postoperatively (1). This may also reduce stress and the pain experience (2).

This theory has been previously evaluated within the literature. As an example, functional performance was improved and pain was reduced for those who ‘prehabilitated’ compared to control patients receiving total knee arthroplasty (3).

The purpose of this randomized clinical study was to evaluate outcomes after the addition of prehabilitation and early rehabilitation in patients undergoing spinal surgery.

Pertinent Results:

The control group (rehab only) consisted of 32 patients and the interventional group (prehab + more intense rehab) consisted of 28 patients. No differences were found between groups at intake. However, the intervention group demonstrated increased function via lower Roland Morris scores at the time of operation. Functional measures showed no differences. No differences were noted in post-operative analgesic use.
  • Less pain was experienced by the interventional group (determined by an area under curve analysis, P = 0.03), who demonstrated a VAS of 41(range 0-78) in the low back and for radiating pain at admission and 31 (2-77) for low back pain at discharge. The control group demonstrated a VAS of 53 (0-96) for low back pain and radiating pain at admission and 21 (0-85).
  • The interventional group was discharged earlier than the control group as shown by a post-operative discharge time of 5 (3-9) days versus 7 (5-15) days. This is a reduced hospital stay of 29%!
  • Further, intervention group milestones were achieved faster, reached within 1-6 days versus 3-13 days for the control group.
  • Satisfaction was shown in 15/28 interventional patients and 7/32 control patients at the time of discharge.
  • Higher pre-operative low back pain intensity was found to be a predictor of postoperative complications. However, this study design has too many limitations and too few patients to fully consider this finding. Being in the control group was the only identified predictor of longer hospital stay.
  • When patients were again evaluated at 1 month, 3 months and 6 months post-operatively, no differences were noted between groups.
  • Exercise compliance among the interventional group measured 85% based on patient logbook entries.
  • The direct costs saved from a reduced hospital stay offset the additional cost of the expanded rehabilitative program.

Clinical Application & Conclusions:

This study, despite its limitations, found that an integrated rehabilitation program showed significantly enhanced functional recovery and reduced hospital stay, without increasing costs, when compared to a less active approach. These results are significant as they emphasize the importance of utilizing conservative methods more efficiently in conjunction with surgical methods.

Additionally, this research is exceedingly important to manual medicine providers, particularly chiropractors and physical therapists. As Neilsen et al. utilized both home-based exercise and manual therapy components such as mobilization postoperatively, therapists can play a much greater role in the surgical preparation and rehabilitation of their patients. Meaning, just because a patient has failed initial conservative therapy and is receiving surgery does not mean that the therapist no longer has a role!

The role of chiropractic is somewhat limited postoperatively based on these results, as manual therapy was considered only as part of inpatient care, an area where chiropractors are typically not utilized. More practically, surgical patients would be likely to see their chiropractor prior to surgery and again after discharge, making this an area where the profession could be more directly utilized for care. Physical therapists are currently involved in all aspects. This also opens a research window for the profession as medium and long term benefits may exist for patients who receive extended manual therapy postoperatively.

This study emphasizes a critical clinical opportunity for evidence-based manual therapists, particularly chiropractors and physical therapists, whereby our healthcare services can be utilized in order to reduce pain and hospital stay while improving postoperative function and recovery in those undergoing spinal surgery.

Study Methods:

For an eighteen month period, consecutive patients presenting for elective spinal surgery were recruited, totaling 88 patients. The reason for pursuing elective surgery was degenerative disease causing low back pain with radiating pain. The decision of whether a patient was to have surgery was made by the surgeon.

Patients were required to participate in the inpatient rehabilitation, be over the age of 18 years and fully understand and participate within the rehabilitation program. Fifteen patients did not meet these requirements.

In total, 73 patients were included within the trial and randomized 6-8 weeks prior to scheduled surgery. Randomization was carried out by a health professional who was not involved within the project, minimizing bias and error. Involved surgeons were also blinded to patient allocation. The study was not completely blinded however as patients were obviously aware of which group they belonged to.

Six of these patients did not exhibit indications for surgery at the time of the planned procedure, 3 withdrew their informed consent and 4 had the procedure performed at another hospital. Therefore, although 38 patients entered the intervention group and 35 entered the control group, only 28 and 32 respectively completed the study and were included for analysis.

A physiotherapist and nurse performed the outcome assessments and administered outcome measures. These included the following:
  • The Brief Pain Inventory Questionnaire
  • The Roland Morris Questionnaire
  • The Sit-to-Stand test: measures the time it takes for the patient to rise from a chair to a standing position and return to a seated position 5 times, quickly.
  • The Timed Up and Go test: measures the time for the patient to rise from a chair, walk a 3 metre straight line, turn, walk back to sit down in the chair.
  • The 15D test: 15 dimensional health related quality of life questionnaire.
  • Pain Intensity: both radiating and low back pain were rated on a 100 point VAS.
  • Patient Milestones: patient achievements during hospital stay included assisted positional change in bed, independent positional change, assisted mobilization in bedside, independent mobilization, assisted mobilization while walking, independent mobilization, independent personal hygiene, independent daily function on ward, walking without aids, complete training program, independent stair climb and discharge.
Postoperative complications were not itemized and were diagnosed by the surgeons. No surgery involved more than two levels, 80% of patients underwent a spondylodesis and 50% decompression and posterolateral fusion.

Interventions:

Control group rehabilitation program: Patients were mobilized on the day of the operation and trained daily for a period of 30 minutes subsequently until discharge. Patients were mobilized daily by a physiotherapist until discharge. There was no further home-based rehabilitation.

Interventional group prehabilitation program: Patients entered a 6-8 week preoperative training program that consisted of a daily 30 minute program which addressed muscular strength of the back and abdomen as well as aerobic exercise, tracked via an exercise logbook. The program was instructed by a physiotherapist at intake, and supervised at 2 weeks post-intake for clarification. Patients were instructed on the operation and postoperative rehabilitation.

Interventional group rehabilitation program: Patients received ‘intense’ mobilization on the day of the operation, and twice daily for 30 minutes subsequently until discharge. Pre-operative exercises continued daily.

Additional group differences:
  • Epidural infusions were provided at roughly ¾ the dosages for the intervention group, with no rationale provided, postoperatively.
  • The interventional group was provided with protein supplementation the evening before the surgery as well as 4 times daily until discharge.

Study Strengths / Weaknesses:

This study held a small sample size, making it difficult to draw strong conclusions from its results, particularly those pertaining to predictors of complications. More notably however is the many variables which differed between the interventional and control group. While objective functional measures and subjective measures of pain experience were equal at baseline between groups, some differences were noted pre-operatively. Given the small sample size, this variable would be difficult to control for.

More importantly however is that the groups were not only separated by a prehabilitation program, but also a postoperative rehabilitation program, the use of protein supplementation (with no provided rationale), the amount of interaction with therapists prior to surgery, the degree of education regarding postoperative rehabilitation prior to surgery, the dosages involved in epidural infusions and the use of a daily exercise logbook only being utilized in the interventional group.

As a result of these many differences between the two groups, one can only conclude that differences existed at discharge. We cannot make firm conclusions on which aspects of this program were most helpful.

Additional References:

  1. Carli et al. Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metab Care 2005; 8:23-32.
  2. Kehlet et al. Fast track surgery. Br J Surg 2005; 92:3-4.
  3. Topp et al. The effect of prehabilitation exercise on strength and functioning after total knee arthoplasty. PM R 2009; 1(8): 729-35.