Earlier rehabilitation leads to lower functional outcomes in lumbar spinal fusion patients

Image: CC/Pleanetc

Key study points:

1. Lumbar fusion surgery patients who initiated rehabilitation at 12-weeks had 4X more functional improvement than those at 6-weeks, at 1 year follow up. Rehabilitation at 12-weeks also resulted in less back pain.
2. There was no difference in pain and function at 6-months follow up.

Primer: Lumbar spinal fusion surgery is an orthopedic procedure performed to treat patients with degenerative disc disease or symptomatic lumbar degenerative disease (ie. Neurogenic claudication). There is contrasting literature on whether patients will benefit from lumbar fusion surgery and few studies have examined rehabilitation strategies. However, recent systematic reviews have shown lumbar fusion surgery leads to greater improvement and functional outcomes compared to non-surgical care for chronic back pain associated with lumbar degeneration.

With surgery, the improved functional outcomes and decrease in pain comes with the trade-off of decreased mobility due the fusion of vertebrae. It is essential for orthopedic surgeons and physical therapists to know rehabilitation timelines and range of motion norms to ensure optimal outcomes for patients post lumbar fusion surgery.

Background reading

1. Systematic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain (SPINE)

 2. Clinical outcomes in older patients after posterolateral lumbar fusion (SPINE)

This [randomized, controlled] study: 290 Danish patients (age 18-64 years) who underwent lumbar fusion surgery due to degenerative disc were selected from three different spine centers from January 2008 to January 2010. Patients were randomly assigned before surgery to begin rehabilitation at 6-weeks or 12-weeks. Rehabilitation included a physical therapist that instructed patients in exercises focusing on stability of the trunk and large muscle groups. An occupational therapist focused on ergonomics and posture.

92 patients were ultimately included in the study. The primary outcome was the Oswestry Disability Index (ODI). Other secondary outcomes including the Low Back Rating Scale, Dallas Pain Questionnaire and days of sick leave were documented. At 1-year follow up, the 6 week group had a median reduction of -6 (-19;4) on the Oswestry Disability Index compared to the 12-week group which had a -20 (-30;-7) reduction (P<0.05). The Dallas Pain Questionnaire showed no difference in outcomes between the two groups. In terms of back pain, the 6 week group had median reduction of -22 (-3.0;-0.7) versus the 12-week group which had a -3.3 (-4.7;-1.7)(P<0.05).

In sum: The authors demonstrated that earlier rehabilitation at 6-weeks post lumbar spine fusion resulted in inferior functional outcomes and decreased performance in activities of daily living. In addition, those same patients also experienced less back pain.

The study had very strong design and internal validity as both treatment groups had similar patient demographics. Nevertheless, other outcome scales such as the LBRS and DPQ did not show any difference between the two treatment groups. This can be attributed to the subjective type questioning of such “functional scales”. More objective measurements would have strengthened the authors’ claims. Lumbar fusion patients are expected to have longer recovery periods and prolonged pain, so comparing to a later start-time (ie 20 weeks) would have been more practical.

Initiating rehabilitation at 12-weeks is currently the more common practice and this “more-delayed” protocol should continue to be utilized in the plan of care. The study also underscores the importance of further reach optimal rehabilitation treatment protocols and timelines for post-operative patients.

Click to read the study in SPINE

By [RZ] and [AH]

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