A Person-Centered Prehabilitation Program Based on Cognitive-Behavioral Physical Therapy for Patients Scheduled for Lumbar Fusion Surgery: A Randomized Controlled Trial

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

How do information and physiotherapy affect health-related quality of life among patients with spinal stenosis undergoing decompression surgery: A qualitative study

BACKGROUND

There is a lack of qualitative research on how patients with lumbar spinal stenosis (LSS) undergoing surgery perceive their health-related quality of life (HRQOL). Research that increases our understanding in this area could facilitate a biopsychosocial approach to care.

AIM

We aimed to investigate the experiences of patients with LSS undergoing decompression surgery regarding their pre- and post-surgery perceptions of HRQOL and the pre-and post-operative information and physiotherapy.

METHOD

We used a qualitative design with semi-structured interviews to perform content analysis using an inductive approach. Twelve patients (7 female, 5 male) were included post-surgery and interviewed by phone. The interviews were recorded and transcribed verbatim.

RESULTS

Four distinct categories with nine associated subcategories were identified: Patients' feelings of safety and empowerment are enhanced by healthcare professionals; Divided perceptions of information and physiotherapy in a group context; Health-related quality of life is associated with patients' perceived physical capacity; Patients' optimism and concerns influence health-related quality of life.

CONCLUSION

Both physical and psychological factors pre- and post-surgery appear to influence patients' HRQOL. Inherent optimism and feelings of empowerment in the care process appear to be important factors, regardless of physical health status. A strong patient-provider relationship is important to promote self-efficacy, which may positively affect perceived HRQOL and is in line with the generally recommended biopsychosocial approach in the treatment of people with low back pain. As qualitative studies in this area are scarce, there is a need for further studies to validate our findings.

Relationship between disability and physical activity frequency after cervical spine surgery: A linear mixed model analysis

BACKGROUND

There is a paucity of data on physical activity and its effects in patients after cervical spine surgery.

OBJECTIVE

This study aimed to examine the association between physical activity and disability in patients after cervical spine surgery while also considering age, sex, pain, and central sensitization (CS)-related symptoms.

METHODS

Participants included individuals with a cervical degenerative condition who had undergone surgery. Neck disability index, physical activity frequency, numerical rating scale for pain intensity, and short form of the CS inventory were recorded more than 1 year postoperatively. The linear mixed model was performed to examine the association between physical activity and disability.

RESULTS

The responses of 145 participants were analyzed. The linear mixed model results showed that the stretching and light-intensity exercise frequency (β=-0.14, p= 0.039) was independently associated with disability, adjusted for age, sex, pain, and CS-related symptoms. Conversely, other physical activities, such as walking and muscle strength exercises, were not associated with a disability.

CONCLUSION

The findings emphasize the importance of performing regular physical activity, regardless of pain and CS-related symptoms.

Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery

OBJECTIVES

To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway.

DESIGN

A cross-sectional, qualitative study with an interpretive descriptive design.

SETTING

Academic and non-academic hospital setting in Belgium.

PARTICIPANTS

31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed.

RESULTS

Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS.

CONCLUSIONS

This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness.

TRIAL REGISTRATION NUMBER

This study was registered at clinicaltrials.gov (NCT03427294).

Preoperative rehabilitation optimization for spinal surgery: a narrative review of assessment, interventions, and feasibility

PURPOSE

Postoperative physical therapy (PT) is a cornerstone of orthopedic and musculoskeletal rehabilitation, proven to provide various positive clinical benefits. However, there is a paucity of literature evaluating the utility of preoperative rehabilitation specific to spine surgery. Thus, this review article aims to provide an overview of previously published studies discussing the efficacy of preoperative rehabilitation programs and its role in spinal surgery. Special emphasis was given to preoperative frailty assessments, physical performance tests, interventional strategies, feasibility, and future directions.

METHODS

We performed a literature review using PubMed, Google Scholar, EMBASE, and PubMed Central (PMC) using directed search terms. Articles that examined preoperative rehabilitation in adult spine surgery were compiled for this review. Prehabilitation programs focused on exercise, flexibility, and behavioral modifications have been shown to significantly improve pain levels and functional strength assessments in patients undergoing elective spine surgery. In addition, studies suggest that these programs may also decrease hospital stays, return to work time, and overall direct health care expenditure costs. Screening tools such as the FRAIL scale can be used to assess frailty while physical function tests like the timed-up-and go (TUGT), 5 repetition sit-to-stand test (5R-STST), and hand grip strength (HGS) can help identify patients who would most benefit from prehabilitation.

CONCLUSIONS

This review illustrates that prehabilitation programs have the potential to increase quality of life, improve physical function and activity levels, and decrease pain, hospital stays, return to work time, and overall direct costs. However, there is a paucity of literature in this field that requires further study and investigation.

The Effect of Graded Activity and Pain Education After Lumbar Spinal Fusion on Sedentary Behavior 3 and 12 Months Postsurgery: A Randomized Controlled Trial

OBJECTIVES

To examine the effect of an early postsurgical intervention consisting of graded activity and pain education (GAPE) in patients with chronic low back pain (CLBP) undergoing lumbar spinal fusion (LSF) on sedentary behavior, disability, pain, fear of movement, self-efficacy for exercise and health-related quality of life (HRQoL) at 3-, 6-, and 12 months follow-up.

DESIGN

A parallel-group, observer-blinded randomized controlled trial.

SETTING

Department of Occupational- and Physiotherapy and the Centre for Rheumatology and Spine Diseases, Rigshospitalet, Denmark.

PARTICIPANTS

In total, 144 participants undergoing an LSF for CLBP were randomly assigned to an intervention or a control group.

INTERVENTIONS

The intervention group received 9 sessions of GAPE, based on principles of operant conditioning.

MAIN OUTCOME MEASURES

The primary outcome was reduction in time spent in sedentary behavior, measured by an accelerometer at 3 months. The secondary outcomes were reduction in time spent in sedentary behavior at 12 months and changes from baseline to 3-, 6-, and 12 months on disability, pain, fear of movement, self-efficacy for exercise, and HRQoL.

RESULTS

No difference in changes in sedentary behavior between groups was found 3 months after surgery. At 12 months after surgery, there was a significant difference between groups (mean difference: -25.4 min/d (95% confidence interval -49.1 to -1.7)) in favor of the intervention group.

CONCLUSIONS

Compared with usual care, GAPE had no effect on short-term changes in sedentary behavior but GAPE had a statistical, but possibly not clinical significant effect on sedentary behavior 12 months after LSF. Further, the behavioral intervention was safe to perform.

Towards a common definition of surgical prehabilitation: a scoping review of randomised trials

BACKGROUND

There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition.

METHODS

The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis.

RESULTS

We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.'

CONCLUSIONS

A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Pain-Associated Psychological Distress Is of High Prevalence in Patients With Hip Pain: Characterizing Psychological Distress and Phenotypes

Purpose

To identify common pain-related psychological factors among patients seeking care for athletic hip pain, as well as characterize psychological distress phenotypes and compare hip-specific quality-of-life measures across those phenotypes.

Methods

A total of 721 patients were recruited from hip preservation clinics. The Optimal Screening for Prediction of Referral and Outcome-Yellow Flag Assessment Tool (OSPRO-YF) was used to identify the presence or absence of 11 different pain-associated psychological distress characteristics (yellow flags), while the International Hip Outcome Tool-12 (iHOT-12) was used to assess hip-related quality of life. Latent class analysis identified patient subgroups (phenotypes) based on naturally occurring combinations of distress characteristics. An analysis of variance was used to compare demographics, number of yellow flags, and iHOT-12 scores across phenotypes.

Results

The median (interquartile range) number of yellow flags was 6 (3-9), with 13.5% of the sample reporting 11 yellow flags. Latent class analysis (L2 = 543.3, classification errors = 0.082) resulted in 4 phenotypes: high distress (n = 299, 41.5%), low distress (n = 172, 23.9%), low self-efficacy and acceptance (n = 74, 10.3%), and negative pain coping (n = 276, 24.4%). Significant differences in mean yellow flags existed between all phenotypes except low self-efficacy and negative pain coping. There were no differences in demographics between phenotypes. The high distress class had the lowest mean iHOT-12 score (mean [SD], 23.5 [17.6]), with significant differences found between each phenotypic class.

Conclusions

There was a high prevalence of pain-associated psychological distress in patients presenting to tertiary hip arthroscopy clinics with hip pain. Furthermore, hip quality-of-life outcome scores were uniformly lower in patients with higher levels of psychological distress.

Level of Evidence

Level III, retrospective cohort study.

Get Back, a person-centred digital programme targeting physical activity for patients undergoing spinal stenosis surgery-a study protocol of a randomized feasibility study

BACKGROUND

Spinal stenosis is the most common reason for elective spine surgery, and the cardinal symptom is leg pain and discomfort when walking. Patients with spinal stenosis have a decreased level of physical activity and thereby an increased risk of poor health. Get Back is a person-centred digital programme that strives to support patients being physically active after surgery. The aim is to explore if Get Back, in its present format (referred to as Get Backfeasibility), is feasible and contributes to detectable change in variables related to intervention content.

METHODS

Thirty patients planned for decompression surgery due to central lumbar spinal stenosis who present with low physical activity, pain catastrophizing or fear of movement, will be included in a randomized feasibility study. All patients will be randomly allocated to either Get Backfeasibility or usual physical therapy. Get Backfeasibility aims to increase the patient's physical activity level by combining a person-centred and cognitive behavioural approach. It comprises 10 video and telephone sessions led by a physical therapist over 12 weeks (pre/postoperatively). Outcomes are treatment fidelity (treatment dose, adherence, and content), process feasibility (recruitment, intervention use, and acceptability of measurements and intervention), and variables related to the intervention content (steps per day, physical activity level, pain catastrophizing, fear of movement, and general self-efficacy). Treatment fidelity and feasibility data will be assessed during the full study period (12 weeks). Physical activity, physical capacity, and patient-reported outcomes will be assessed digitally at baseline (2 weeks preoperatively) and 11-12 weeks postoperatively. Variables related to the intervention content will be monitored weekly through a digital application. Feasibility data will be analysed descriptively and inferentially using a nonparametric approach, data from repeated measures will be displayed graphically and data from telephone interviews will be analysed using content analysis with a descriptive manifest approach.

DISCUSSION

The results will provide information on whether Get Back in its present format is feasible and can be evaluated for effectiveness in a larger randomized controlled trial, for patients with a low physical activity level and a high fear of movement who are undergoing decompression surgery.

TRIAL REGISTRATION

Registered at ClinicalTrails.gov 04/08/2023, registration no. NCT05806593.

Physical therapist-led interventions based on the biopsychosocial model provide improvement in disability and pain for spinal disorders: A systematic review and meta-analysis

OBJECTIVE

To summarize the effects of physical therapist-led interventions based on the biopsychosocial (BPS) model in spinal disorders compared to interventions with no BPS model through a systematic review and meta-analysis of randomized-controlled trials. TYPE: Systematic review and meta-analysis.

LITERATURE SURVEY

We searched the Web of Science, CENTRAL, MEDLINE, PsycINFO, CINAHL, and PEDro up to October 27, 2022.

METHODOLOGY

Pain intensity and disability were primary outcomes and psychological factors were secondary outcomes in spinal disorders. The included intervention was physical therapist-led interventions based on the BPS model. The control group received no physiotherapy intervention for BPS. Pooled effects were analyzed as standardized mean differences (SMDs) and 95% confidence intervals (CIs), and the random-effects model was used for the meta-analysis. The subgroup analysis was divided into low back pain group and neck pain group. Another subgroup analysis was conducted only of the groups that had received training of the BPS model.

SYNTHESIS

Fifty-seven studies with 5471 participants met the inclusion criteria. For pain intensity, there was a statistically significant effect for the BPS model led by physical therapists in the short, medium, and long terms. The SMDs with 95% CIs were -0.44 (-0.62, -0.27), -0.24 (-0.37, -0.12), and -0.17 (-0.28, -0.06), respectively. Outcomes were clinically significant, except in the long term. For disability, there was a statistically significant effect in the short, medium, and long terms. The SMDs with 95% CIs were -0.48 (-0.69, -0.27), -0.44 (-0.64, -0.25), and -0.37 (-0.58, -0.15), respectively. All periods were clinically significant. The quality of the evidence was low for all of the main outcomes for all of the terms.

CONCLUSION

Physical therapist-led interventions based on the BPS model effectively improve pain intensity and disability in patients with spinal disorders based on low-quality evidence.

[Physiotherapy in rehabilitation of patients with degenerative disk diseases from positions of evidence-based medicine: a literature review]

Back pain is one of the most urgent problems of rehabilitation. Patients with this pathology have a leading place among neurological patients in terms of the number of days of disability. The high economic costs in society are explained by the need for lumbar surgery (discectomy, spinal fusion and disc prosthesis) and rehabilitation after it. The effectiveness of rehabilitative measures is determined both by the patient's rehabilitative potential and by the choice of rehabilitative methods.

OBJECTIVE

To evaluate the effectiveness of physiotherapy in patients with degenerative disk diseases from positions of evidence-based medicine according to the scientific and technical literature.

MATERIAL AND METHODS

The analysis of scientific and technical literature sources and the study of materials of meta-analyses, systematic reviews (depth of search was 20 years) on the evaluation of effectiveness of physiotherapeutical methods in the rehabilitation of patients with degenerative disk diseases have been conducted.

RESULTS

The ability of pulsed magnetic field to reduce the intensity of pain and improve the functional capacities of the spine in patients with low back pain has been identified. There was a pronounced analgesic end-point of low-level laser therapy in acute and chronic back pain at short and medium-term (up to 12 months) observation, as well as the ability of the method to reduce temporary disability in degenerative disk diseases.

CONCLUSION

The use of magnetotherapy and low-level laser therapy can be recommended for the treatment of patients with degenerative disk diseases (C grade of recommendations, 3rd level of evidence). The recommendation is based on the results of 10 RCTs (1.111 patients with degenerative disk diseases), 3 meta-analyses, 1 systematic review and 1 Cochrane review (a total of 3.431 patients).

Fear of movement was associated with sedentary behaviour 12 months after lumbar fusion surgery in patients with low back pain and degenerative disc disorder

BACKGROUND

Movement behaviours, such as sedentary behaviour (SB) and moderate to vigorous physical activity (MVPA), are linked with multiple aspects of health and can be influenced by various pain-related psychological factors, such as fear of movement, pain catastrophising and self-efficacy for exercise. However, the relationships between these factors and postoperative SB and MVPA remain unclear in patients undergoing surgery for lumbar degenerative conditions. This study aimed to investigate the association between preoperative pain-related psychological factors and postoperative SB and MVPA in patients with low back pain (LBP) and degenerative disc disorder at 6 and 12 months after lumbar fusion surgery.

METHODS

Secondary data were collected from 118 patients (63 women and 55 men; mean age 46 years) who underwent lumbar fusion surgery in a randomised controlled trial. SB and MVPA were measured using the triaxial accelerometer ActiGraph GT3X+. Fear of movement, pain catastrophising and self-efficacy for exercise served as predictors. The association between these factors and the relative time spent in SB and MVPA 6 and 12 months after surgery was analysed via linear regression models, adjusting for potential confounders.

RESULTS

Preoperative fear of movement was significantly associated with relative time spent in SB at 6 and 12 months after surgery (β = 0.013, 95% confidence interval = 0.004 to 0.022, p = 0.007). Neither pain catastrophising nor self-efficacy for exercise showed significant associations with relative time spent in SB and MVPA at these time points.

CONCLUSIONS

Our study demonstrated that preoperative fear of movement was significantly associated with postoperative SB in patients with LBP and degenerative disc disorder. This finding underscores the potential benefits of preoperative screening for pain-related psychological factors, including fear of movement, preoperatively. Such screenings could aid in identifying patients who might benefit from targeted interventions to promote healthier postoperative movement behaviour and improved health outcomes.

Becoming partners in rehabilitation with patients in intensive care: physiotherapists' perspectives

PURPOSE

Person-centred care is widely accepted as being central to high quality care, but little is known about how physiotherapists implement person centred rehabilitation in Intensive Care. This study explores the self-reported experiences and interpretations of physiotherapists delivering person-centred rehabilitation in this setting.

METHODS

A qualitative study using Interpretative Phenomenological Analysis explored the lived experiences of physiotherapists and students who have worked in Intensive Care. Three focus groups, with four participants in each, were conducted. Data were fully transcribed, analysed and managed using NVivo software.

RESULTS

Participants shared similar interpretations about the principles of person-centred care. Operationalising person-centred rehabilitation during early recovery was not easily achievable. As the person's clinical condition improved, participants moved away from routine physiotherapy and their practice became more person-centred through the development of a partnership. Participants connected as humans to understand the person and respond to their needs within a culture that valued person-centred care.

CONCLUSIONS

Physiotherapists aspire to develop a partnership with their patients by connecting on a human level with them and addressing their biopsychosocial needs. Physiotherapists with experience of developing patient partnerships influence the culture of the Intensive Care team and are role-models to facilitate collaborative person-centred activity in others.

Prehabilitation for spine surgery: A scoping review

We aimed to identify and describe the current interventions used in preoperative programs ("prehabilitation") for spine surgery. Knowledge gaps in approaches, feasibility, timing, patient experience, clinical outcomes, and health care costs were explored while describing their potential benefits on physical and psychological outcomes. An electronic search was conducted from January 2004 to February 2022 in Ovid Medline, Embase, EBSCO CINAHL, the Cochrane Database of Systematic Reviews, and PEDro to identify studies in English evaluating adults enrolled in prehabilitation before undergoing elective spine surgeries. Studies were uploaded into DistillerSR for systematic screening after removing duplicates. Four reviewers screened nested references for inclusion based on titles and abstracts, followed by their full-text review. Two reviewers subsequently extracted data and summarized the results. The results were reported using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Studies were rated for quality using National Health and Medical Research Council criteria. Out of 18,879 potential studies, a total of 23 studies (0.12%) met the eligibility criteria and were included in this scoping review. The prehabilitation programs included general education (n = 6, 26%), exercise (n = 6, 26%), cognitive behavioral therapy (n = 3, 13%), pain neuroscience education (n = 3, 13%), health behavior counseling (n = 3, 13%), and mindfulness (n = 2, 9%). Additional studies are needed to identify optimal patient characteristics, intervention dosage, and whether multimodal approaches using a combination of physical and psychological strategies lead to more favorable outcomes. Although studies on prehabilitation for spine surgery are limited, they seem to demonstrate that prehabilitation programs are feasible, reduce medical expenditures, and improve patients' postoperative pain, disability, self-efficacy, psychological behaviors, and satisfaction with surgical outcomes. The available literature suggests there is an opportunity to improve patient experience, clinical outcomes and reduce medical costs with the use of prehabilitation in spine surgery.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review

BACKGROUND

Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists.

METHODS

Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions.

SOURCES OF EVIDENCE

search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane.

CHARTING METHODS

identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD).

RESULTS

We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1).

CONCLUSION

Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses

BACKGROUND

Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence.

METHODS AND FINDINGS

A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials).

CONCLUSIONS

Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.

Multimodal Prehabilitation in Heart Transplant Recipients Improves Short-Term Post-Transplant Outcomes without Increasing Costs

(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.

Are We Considering the Whole Patient? The Impact of Physical and Mental Health on the Outcomes of Spine Care

STUDY DESIGN

Retrospective, observational.

OBJECTIVE

To evaluate the influence of baseline health status on the physical and mental health (MH) outcomes of spine patients.

SUMMARY OF BACKGROUND DATA

Spine conditions can have a significant burden on both the physical and MH of patients. To date, few studies have evaluated the outcomes of both dimensions of health, particularly in nonoperative populations.

MATERIALS AND METHODS

At their first visit to a multidisciplinary spine clinic, 2668 nonoperative patients completed the Patient-reported Outcomes Measurement Information System-Global Health (PROMIS-GH) instrument and a questionnaire evaluating symptoms and goals of care. Patients were stratified by their baseline percentile score of the MH and physical health (PH) components of the PROMIS-GH. Four groups of patients were compared based on the presence or absence of bottom quartile PH or MH scores. The primary end point was the achievement of a minimal clinically important difference (MCID) on the MH or PH components at follow-up. Multivariate regression assessed the predictors of MCID achievement.

RESULTS

After controlling for demographics, symptoms, and goals, each 1-point increase in baseline PROMIS-GH mental score reduced the odds of achieving MH MCID by 9.0% ( P <0.001). Conversely, each 1-point increase in baseline GH-physical score increased the odds of achieving MCID by 4.5% ( P =0.005). Each 1-point increase in baseline GH-physical score reduced the odds of achieving PH MCID by 12.5% ( P <0.001), whereas each 1-point increase in baseline GH-mental score increased the odds of achieving MCID by 5.0% ( P <0.001).

CONCLUSIONS

Spine patients presenting with the lowest levels of physical or MH were most likely to experience clinically significant improvement in those domains. However, lower levels of physical or mental health made it less likely that patients would experience significant improvement in the alternative domain. Physicians should evaluate and address the complex spine population holistically to maximize improvement in both physical and mental health status.

Can perioperative psychological interventions reduce chronic pain after surgery?

Chronic post-surgical pain is a relatively common adverse effect following surgery. Several prognostic factors for chronic post-surgical pain have been identified, including psychological states and traits. Psychological factors are modifiable, and perioperative psychological interventions may reduce the incidence of chronic post-surgical pain. A meta-analysis showed preliminary evidence for the benefits of such interventions for the prevention of chronic post-surgical pain. Further research must be conducted to better understand the specific type, intensity, duration and timing of interventions that are most effective. The number of studies in this area has recently increased, with additional randomised controlled trials currently being carried out, which may allow for the development of more robust conclusions in the coming years. In order to implement perioperative psychological care alongside routine surgical interventions, efficient and accessible interventions should be available. In addition, demonstration of cost-effectiveness may be a prerequisite for wider adoption of perioperative psychological interventions in regular healthcare. Offering psychological interventions selectively to patients at risk of chronic post-surgical pain could be a means to increase cost-effectiveness. Stepped-care approaches should also be considered, where the intensity of psychological support is adapted to the needs of the patient.

Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis

Importance

Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results.

Objective

To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery.

Data Sources

Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022.

Study Selection

Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included.

Data Extraction and Synthesis

Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Pain, function, muscle strength, and health-related quality of life (HRQOL).

Results

Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence.

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.

The Rehabilitation-Related Effects on the Fear, Pain, and Disability of Patients With Lumbar Fusion Surgery: A Systematic Review and Meta-Analysis

Objective: The lumbar fusion is an important surgery for the orthopedic diseases. The rehabilitation might improve the outcome of patients with lumbar fusion surgery. The rehabilitation-related effects can be revealed by a systemic review and meta-analysis of randomized clinical trials (RCTs). The purpose of this study is to clarify the rehabilitation effects in the patients with lumbar fusion surgery.Methods: We performed a systematic search and a meta-analysis for the RCT of rehabilitation treatment on the patients with lumbar fusion surgery. The comparison between rehabilitation treatment (including psychological rehabilitation, exercise, and multimodal rehabilitation) and typical treatment was performed to find if the rehabilitation treatment can improve the outcome after the lumbar fusion surgery. Fifteen studies of lumbar fusion patients under rehabilitation treatment and typical treatment were enrolled in a variety of rehabilitation modalities. The focused outcome was the rehabilitation-related effects on the fear, disability, and pain of patients after the lumbar fusion surgery.Results: Five hundred twenty-eight rehabilitation subjects and 498 controls were enrolled. The psychological-related rehabilitation showed a significant decrease in pain-related fear when compared to usual treatment. The multimodal rehabilitation can improve the disability outcome to a greater extent when compared to usual treatment. The multimodal rehabilitation seemed to have a more significantly positive effect to decrease disability after lumbar fusion surgery. In addition, the exercise and multimodal rehabilitation can relieve the pain after lumbar fusion surgery. The exercise rehabilitation seemed to have a more significantly positive effect to relieve pain after lumbar fusion surgery.Conclusion: The rehabilitation might relieve the pain-related fear, disability, and pain after lumbar fusion surgery.

Effectiveness of the perioperative encounter in promoting regular exercise and physical activity: a systematic review and meta-analysis

BACKGROUND

Low levels of physical activity (PA) are associated with poorer health outcomes. The perioperative encounter (extending from initial contact in primary care to beyond discharge from hospital) is potentially a good time to intervene, but data regarding the effectiveness of interventions are scarce. To address this, we systematically reviewed existing literature to evaluate the effectiveness of interventions applied perioperatively to facilitate PA in the medium to long-term (at least six months after the intervention).

METHODS

In this systematic review and meta-analysis, we searched Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, CINAHL, Embase, PsycInfo, and SPORTDiscus from database inception to October 22nd 2020, with an updated search done on August 4th 2022. We searched clinical trials registers, and conducted forward- and backward-citation searches. We included randomised controlled trials and quasi-randomised trials comparing PA interventions with usual care, or another PA intervention, in adults who were scheduled for, or had recently undergone, surgery. We included trials which reported our primary outcomes: amount of PA or whether participants were engaged in PA at least six months after the intervention. A random effects meta-analysis was used to pool data across studies as risk ratios (RR), or standardised mean differences (SMDs), which we interpreted using Cohen. We used the Cochrane risk of bias tool and used GRADE to assess the certainty of the evidence. This study is registered with PROSPERO, CRD42019139008.

FINDINGS

We found 57 trials including 8548 adults and compared 71 interventions facilitating PA. Most interventions were started postoperatively and included multiple components. Compared with usual care, interventions may slightly increase the number of minutes of PA per day or week (SMD 0.17, 95% CI 0.09-0.26; 14 studies, 2172 participants; I² = 0%), and people's engagement in PA at the study's end (RR 1.19, 95% CI 0.96-1.47; 9 studies, 882 participants; I² = 25%); this was moderate-certainty evidence. Some studies compared two different types of interventions but it was often not feasible to combine data in analysis. The effect estimates generally indicated little difference between intervention designs and we judged all the evidence for these comparisons to be very low certainty. Thirty-six studies (63%) had low risk of selection bias for sequence generation, 27 studies (47%) had low risk of bias for allocation concealment, and 56 studies (98%) had a high risk of performance bias. For detection bias for PA outcomes, we judged 30 studies (53%) that used subjective measurement tools to have a high risk of detection bias.

INTERPRETATION

Interventions delivered in the perioperative setting, aimed at enhancing PA in the medium to long-term, may have overall benefit. However, because of imprecision in some of the findings, we could not rule out the possibility of no change in PA.

FUNDING

National Institute for Health Research Health Services and Delivery Research programme (NIHR127879).

Effect of integrated exercise therapy and psychosocial interventions on self-efficacy in patients with chronic low back pain: A systematic review

OBJECTIVE

Investigate if integrated exercise and psychosocial (EP) interventions effect self-efficacy to manage pain and self-efficacy for physical functioning compared to alternate interventions, usual care, waitlists and attention controls for individuals with chronic low back pain (CLBP).

METHODS

MEDLINE, Embase, CINAHL, Web of Science, PsychINFO, PEDro, and Cochrane Library were searched. Included randomized controlled trials utilized an EP intervention for CLBP and measured self-efficacy. Independent reviewers screened abstracts, reviewed full-texts, extracted data, and assessed risk of bias. GRADE, synthesis without meta-analysis, and ranges of effects (Hedges' g) were used.

RESULTS

2207 Participants were included (22-studies). EP interventions positively effected self-efficacy to manage pain short-term compared to usual care (range of effects: -0.02, 0.94) and controls (range of effects: 0.69, 0.80) and intermediately compared to usual care (range of effects: 0.11, 0.29); however, no differences were found when compared to alternate interventions. EP interventions positively effected self-efficacy for physical functioning short-term compared to alternate interventions (range of effects: 0.57, 0.71), usual care (range of effects: -0.15, 0.94), and controls (range of effects: 0.31, 0.56), and intermediately compared to alternate interventions (1-study, effect: 0.57) and controls (1-study, effect: 0.56). Conclusions were limited by low to very low-quality-evidence often from risk of bias, imprecision, and clinical/statistical heterogeneity.

CONCLUSIONS

EP interventions may be more effective short-term for self-efficacy to manage pain than usual care and waitlists, but not alternate interventions. EP interventions may be effective for self-efficacy for physical functioning at short- and intermediate-term compared to alternate interventions, usual care, waitlist and attention controls. Considerations for future research include methods for blinding and measurement of self-efficacy for physical functioning.

The impact of physical and psychological pain management training on pain intensity, anxiety and disability in patients undergoing lumbar surgeries

BACKGROUND/CONTEXT

Lumbar surgery is one of the interventions performed for patients with degenerative conditions.

PURPOSE

This study aimed to investigate the effect of pain management education on pain intensity, anxiety, and disability after the lumbar surgery.

STUDY DESIGN/SETTING

This randomized controlled trial was performed on seventy 30 to 65-year-old patients with lumbar canal stenosis and lumbar disc herniation from 2018 to 2019.

PATIENT SAMPLE

Seventy participants were randomly divided into a control and an intervention group by a randomized block design. Participants in the intervention group received in-person pain management training twice a week for seven 60 to 90-minute sessions.

OUTCOME MEASURES

All participants in the two groups completed the study instruments (numeric rating scale [NRS], Oswestery disability index [ODI], and pain anxiety symptoms scale [PASS]) before, immediately after, and 3 months after the study.

METHODS

Participants in the intervention group received in-person pain management training twice a week for seven 60 to 90-minute sessions. To analyze the treatment effects, repeated-measures multivariate analysis of variance (MANOVA) and effect sizes were used where appropriate and calculated by Partial ɳ². Clinical outcome (MDC) for pain intensity and PASS was also reported. For participants lost to follow-up, we also used an "intention-to-treat" (ITT) approach.

RESULTS

The results of MANOVA indicated that there were significant differences between the two groups on ratings of pain intensity, anxiety, and disability. According to the MDC, the mean differences of pain intensity for the intervention group was also clinically improved. Meanwhile, the mean differences in pain anxiety between three different times in the two groups were not above the MDC (20.14), suggesting that the clinical improvements were not significant. The results were confirmed for all outcome measures; a statistically significant difference was found between the groups in ITT analyses (p<.001).

CONCLUSIONS

Physical and psychological pain management education was shown to be effective in decreasing pain intensity, anxiety, and disability. This strategy may be beneficial for such patients. Variables such as smoking behavior, past history of psychological disorders, and previous surgeries should be considered in future studies.

The effect of perioperative psychological interventions on persistent pain, disability, and quality of life in patients undergoing spinal fusion: a systematic review

PURPOSE

Patients undergoing spinal fusion are prone to develop persisting spinal pain that may be related to pre-existent psychological factors. The aim of this review was to summarize the existing evidence about perioperative psychological interventions and to analyze their effect on postoperative pain, disability, and quality of life in adult patients undergoing complex surgery for spinal disorders. Studies investigating any kind of psychological intervention explicitly targeting patients undergoing a surgical fusion on the spine were included.

METHODS

We included articles that analyzed the effects of perioperative psychological interventions on either pain, disability, and/or quality of life in adult patients with a primary diagnosis of degenerative or neoplastic spinal disease, undergoing surgical fusion of the spine. We focused on interventions that had a clearly defined psychological component. Two independent reviewers used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to perform a systematic review on different databases. Risk of bias was evaluated using the Downs and Black checklist. Given study differences in outcome measures and interventions administered, a meta-analysis was not performed. Instead, a qualitative synthesis of main results of included papers was obtained.

RESULTS

Thirteen studies, conducted between 2004 and 2017, were included. The majority were randomized-controlled trials (85%) and most patients underwent lumbar fusion (92%). Cognitive behavioral therapy (CBT) was used in nine studies (69%). CBT in the perioperative period may lead to a postoperative reduction in pain and disability in the short-term follow-up compared to care as usual. There was less evidence for an additional effect of CBT at intermediate and long-term follow-up.

CONCLUSION

The existing evidence suggests that a reduction in pain and disability in the short-term, starting from immediately after surgery to 3 months, is likely to be obtained when a CBT approach is used. However, there is inconclusive evidence regarding the long-term effect of a perioperative psychological intervention after spinal fusion surgery. Further research is necessary to better define the frequency, intensity, and timing of such an approach in relation to the surgical intervention, to be able to maximize its effect and be beneficial to patients.

Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review

Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.

Association between muscle health and patient-reported outcomes after lumbar microdiscectomy: early results

BACKGROUND CONTEXT

Poor muscle health has been implicated as a source of back pain among patients with lumbar spine pathology. Recently, a novel magnetic resonance imaging (MRI)-based lumbar muscle health grade was shown to correlate with health-related quality of life scores. However, the impact of muscle health on postoperative functional outcomes following spine surgery remains to be investigated.

PURPOSE

To determine whether muscle health grade measured by preoperative psoas and paralumbar muscle cross-sectional areas impact the achievement of minimal clinically important difference (MCID) following lumbar microdiscectomy.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Consecutive patients who underwent 1-level lumbar microdiscectomy in a single institution between 2017 and 2021.

OUTCOME MEASURES

Rate of MCID achievement, time to MCID achievement, PROMs including Oswestry Disability Index (ODI), visual analog scale for back pain (VAS back), VAS leg, Short Form 12 Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), and Patient Reported Outcomes Measurement Information System Physical Function (PROMIS PF).

METHODS

Two previously validated methods for muscle health grading were applied. Axial T2 MRI were analyzed for muscle measurements. The psoas-based method utilized the normalized total psoas area (NTPA), which is the psoas cross-sectional area divided by the square of patient height (mm²/m²). Patients were divided into low and high NTPA groups based on sex-specific lowest quartile NTPA thresholds. The paralumbar-based method incorporated the paralumbar cross-sectional area normalized by body mass index (PL-CSA/BMI) and Goutallier classification. Score of 1 was added for either PL-CSA/BMI >130 or Goutallier class of ≤2. "Good" muscle health was defined as score of 2, and "poor" muscle health was defined as score of 0 to 1. Prospectively collected PROMs were analyzed at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year postoperative timepoints. The rate of and time to MCID achievement were compared among the cohorts. Bivariate analyses were performed to assess for correlations between psoas/paralumbar cross-sectional areas and change in PROM scores from baseline.

RESULTS

The total cohort included 163 patients with minimum follow-up of 6 months and mean follow-up of 16.5 months. 40 patients (24.5%) were categorized into the low NTPA group, and 55 patients (33.7%) were categorized into the poor paralumbar muscle group. Low NTPA was associated with older age, lower BMI, and greater frequencies of Charlson Comorbidity Index (CCI) ≥1. Poor paralumbar muscle health was associated with older age, female sex, higher BMI, and CCI ≥1. There were no differences in rates of MCID achievement for any PROMs between low versus high NTPA groups or between poor versus good paralumbar groups. Low NTPA was associated with longer time to MCID achievement for ODI, VAS back, VAS leg, and SF-12 MCS. Poor paralumbar muscle health was associated with longer time to MCID achievement for VAS back, VAS leg, and SF-12 PCS. NTPA negatively correlated with change in VAS back (6-week, 12-week) and VAS leg (6-month). PL-CSA/BMI positively correlated with change in PROMIS-PF at 3 months follow-up.

CONCLUSIONS

Among patients undergoing lumbar microdiscectomy, patients with worse muscle health grades achieved MCID at similar rates but required longer time to achieve MCID. Lower NTPA was weakly correlated with larger improvements in pain scores. PL-CSA/BMI positively correlated with change in PROMIS-PF. Our findings suggest that with regards to functional outcomes, patients with worse muscle health may take longer to recuperate postoperatively compared to those with better muscle health.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery.

METHODS

In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression.

RESULTS

Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted.

CONCLUSIONS

Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning.

IMPACT

This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.

Effect of Cognitive Behavioral Therapy on Stress Disorder, Cognitive Function, Motor Function, and Daily Living Ability of Patients with a Traumatic Brain Injury

Purpose

The aim of the study is to observe the effects of cognitive behavioral therapy on stress disorder, cognitive function, motor function, and daily living ability of traumatic brain injury (TBI) patients.

Methods

84 patients with TBI admitted to our hospital from June 2019 to May 2021 were selected as the research subjects. They were divided into a control group (from June 2019 to May 2020) and an observation group (from June 2020 to May 2021), with 42 cases in each group. The control group received routine intervention; the observation group received cognitive behavioral therapy on the basis of the control group. Before and after intervention, the posttraumatic stress disorder (PTSD), cognitive function, motor function, and daily living ability of the two groups were observed.

Results

After intervention, the PTSD-self-rating scale (PTSD-SS) scores of both groups were lower than those before intervention, and the PTSD-SS scores of the observation group were lower than those of the control group (P < 0.05). After intervention, the scores of the Montreal cognitive assessment (MoCA) scale, Fugl-Meyer assessment (FMA), and modified Barthel index (MBI) in both groups were higher than those before intervention, and the scores of MoCA, FMA, and MBI in the observation group were higher than those in the control group (P < 0.05).

Conclusion

The application of cognitive behavioral therapy to TBI patients is beneficial to reduce the degree of PTSD and improve cognitive function, motor function, and daily living ability, which is worthy of clinical application.

Development of a machine-learning based model for predicting multidimensional outcome after surgery for degenerative disorders of the spine

BACKGROUND

It is clear that individual outcomes of spine surgery can be quite heterogeneous. When consenting a patient for surgery, it is important to be able to offer an individualized prediction regarding the likely outcome. This study used a comprehensive set of data collected over 12 years in an in-house registry to develop a parsimonious model to predict the multidimensional outcome of patients undergoing surgery for degenerative pathologies of the thoracic, lumbar or cervical spine.

METHODS

Data from 8374 patients (mean age 63.9 (14.9-96.3) y, 53.4% female) were used to develop a model to predict the 12-month scores for the Core Outcome Measures Index (COMI) and its subdomain scores. The data were split 80:20 into a training and test set. The top predictors were selected by applying recursive feature elimination based on LASSO cross validation models. Based on the 111 top predictors (contained within 20 variables), Ridge cross validation models were trained, validated, and tested for each of 9 outcome domains, for patients with either "Back" (thoracic/lumbar spine) or "Neck" (cervical spine) problems (total 18 models).

RESULTS

Among the strongest outcome predictors in most models were: preoperative scores for almost all COMI items (especially axial pain (back or neck) and peripheral pain (leg/buttock or arm/shoulder)), catastrophizing, fear avoidance beliefs, comorbidity, age, BMI, nationality, previous spine surgery, type and spinal level of intervention, number of affected levels, and surgeon seniority. The R² of the models on the validation/test sets averaged 0.16/0.13. A preliminary online tool was programmed to present the predicted outcomes for individual patients, based on their presenting characteristics. https://linkup.kws.ch/prognostictool .

CONCLUSION

The models provided estimates to enable a bespoke prediction of the outcome of surgery for individual patients with varying degenerative pathologies and baseline characteristics. The models form the basis of a simple, freely-available online prognostic tool developed to improve access to and usability of prognostic information in clinical practice. It is hoped that, following confirmation of its validity and practical utility, the tool will ultimately serve to facilitate decision-making and the management of patients' expectations.

A Person-Centred Prehabilitation Program based on Cognitive-Behavioural Physical Therapy for patients scheduled for Lumbar Fusion surgery: A mediation analysis to assess fear of movement (kinesiophobia), self-efficacy, and catastrophizing as mediators of health outcomes

Objective

To investigate whether early changes in fear of movement (kinesiophobia), self‐efficacy and catastrophizing were mediators of the relationship between allocation to the pre‐habilitation intervention and later changes in health outcomes.

Methods

The original pre‐habilitation trial (PREPARE, ISRCTN17115599) recruited 118 participants awaiting lumbar fusion surgery, half of whom received a prehabilitation intervention designed based on the modified fear‐avoidance model and half of whom received usual care. Mediation analysis was performed to test each mediator separately. Analysis was performed on each outcome of interest separately (Oswestry disability index, patient‐specific function, EQ general health and moderate/vigorous physical activity). Mediation analysis was carried out using PROCESS. Beta coefficients and bootstrapped 95% CIs were used to interpret the results.

Results

None of the potential mediators was found to mediate the relationship between allocation to the intervention and 3‐month scores on any of the health outcomes tested.

Conclusions

Screening patients for higher levels of catastrophizing and fear avoidance and lower levels of self‐efficacy could help ensure only the patients who are most likely to benefit from the intervention are included.

Significance

Prehabilitation interventions for spinal fusion surgery have been found to improve health outcomes for patients. Theory‐based interventions that target key mechanisms are more effective at improving outcomes than non‐theory‐based interventions. While no mediating effects were found for this particular intervention, the analysis suggests that the underlying theoretical model and treatment targets are appropriate and could drive improvement if more strongly targeted.

Can perioperative psychological interventions decrease the risk of postsurgical pain and disability? A systematic review and meta-analysis of randomized controlled trials

ABSTRACT

Many patients experience pain after surgery. Psychological factors such as emotion and cognition are shown to be associated with the development of acute and chronic postsurgical pain (CPSP). Therefore, the question arises whether targeting these psychological factors can reduce negative postsurgical outcomes. The aim of the current review was to investigate the efficacy of perioperative psychological interventions in reducing (sub)acute postsurgical pain and CPSP and disability in adults. Randomized controlled trials were identified through 4 databases (Web of Science, PsychINFO, PubMed, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]). The outcomes of interest were (sub)acute (ie, within 3 months after surgery) and chronic (>3 months after surgery) pain and disability. After screening, 21 studies were included in the final analyses. It was found that psychological interventions significantly reduced (sub)acute pain (d = -0.26, 95% confidence interval [CI] [-0.48 to -0.04]) and disability (d = -0.43, 95% CI [-0.84 to -0.03]) as well as CPSP (d = -0.33, 95% CI [-0.61 to -0.06]) and disability (d = -0.43, 95% CI [-0.68 to -0.18]). In addition, interventions delivered after surgery and interventions delivered by a psychologist tended to be more effective than interventions delivered before surgery and interventions delivered by another healthcare provider. Furthermore, the current review points to the need for more research to determine which specific type of intervention may be most beneficial for surgical patients. Finally, the current review identified that research in this domain has concerns regarding bias in missing outcome data due to withdrawal and drop out.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis

PURPOSE

To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis.

METHODS

Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE.

RESULTS

In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies).

CONCLUSION

There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

Physical therapy of patients undergoing first-time lumbar discectomy: a survey of current UK practice

BACKGROUND

The type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers.

METHOD

Physical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing (preop, postop), and rehabilitation content for patients undergoing lumbar discectomy.

RESULTS

Seventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription.

CONCLUSIONS

Whilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery.

Thoughts on Pain, Physical Activity, and Body in Patients With Recurrent Low Back Pain and Fear: An Interview Study

OBJECTIVE

The purpose of this study was to explore thoughts and ideas about the body and pain in patients with nonspecific low back pain (LBP) who have a high degree of fear of movement.

METHODS

Patients with nonspecific LBP and a high degree of fear of movement, as measured using the Tampa Scale of Kinesiophobia, were asked to participate in the study. Individual semistructured in-depth interviews were conducted with 11 participants. The material was analyzed using content analysis with an inductive approach.

RESULTS

From these patients' stories, an overarching theme-decreased confidence in the body becomes a barrier to living life to the fullest-emerged. This theme was further divided into 4 subthemes: (1) "What is wrong with my body?"-the constant search for an explanation; (2) searching for the right way to move; (3) loss of mobility means a lack of meaning in life; and (4) the message from health care professionals guides feelings, thoughts, and movement behavior.

CONCLUSION

This study indicates that the message of keeping physically active when experiencing LBP has succeeded, but patients with fear require support to feel secure and have enough confidence in their body to move and exercise. Clinicians need to better incorporate evidence-based practice for patients with fear and support them so that they can apply an understanding of pain to their bodies and their every day life.

IMPACT

These results offer guidance for health care professionals to enhance their practice by providing more updated information to their patients who have recurrent LBP and fear. With better support, patients may be able to regain confidence in their bodies and live their lives to the fullest.

LAY SUMMARY

If you have recurrent LBP and fear of moving your body, ask your health care professional to provide you with updated knowledge on pain and to help you regain confidence in your body so that you can live your life to the fullest.

"I don't opt out of things because I think I will get a sore knee, but I don't expose myself to stupid risks either": patients' experiences of a second ACL injury-an interview study

PURPOSE

The purpose of this qualitative study was to describe women's experiences with anterior cruciate ligament reconstruction (ACLR) and a subsequent ACL rupture, and to identify potential facilitators and barriers for coping with rehabilitation after the second injury.

METHODS

Eight women between 17 and 36 years (mean 26, SD 6.5) who had experienced ACLR, followed by another ACL rupture, participated in the study. Semi-structured interviews were conducted, and data were analyzed using qualitative content analysis.

RESULTS

One overarching theme, "Rehabilitation after a second ACL injury-A lifelong adaptive coping process", emerged from analyses. Undergoing a second rehabilitation is described as a process of adaptation, beginning with the first injury and still ongoing, more than 5 years later. Participants applied different coping strategies to adapt to these life-altering injuries, but the common denominator was of major life adjustments with no return to previous activity levels. Initially, after the reinjury, it was about coping with the catastrophe of the dreaded second injury. Over time, they accepted their "new" life and reset their recovery/rehabilitation goal not just as "return to sport" but rather as a "personal life goal".

CONCLUSION

Undergoing a second ACL injury is a long process that challenges the patient's coping skills. Given these results, rehabilitation programs need to be more person centred according to the patients-adjusted life goals.

Benefits of the Enhanced Recovery After Surgery Program (ERAS) in Short-segment Posterior Lumbar Interbody Fusion Surgery

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based approach to perioperative care that aims to reduce physiological and psychological stress, improve the quality of rehabilitation and speed up the recovery of patients. Our study aims to investigate the benefits of perioperative use of ERAS for short-segment posterior lumbar interbody fusion (PLIF).

METHODS

We selected two 1-year periods: the first from before the establishment of the multidisciplinary ERAS team in January 2017 (pre-ERAS year 2016) and the second period when ERAS was applied widely in our hospital (ERAS year 2019). Data were collected from the electronic medical records of patients who had undergone short-level PLIF during these 2 periods. The primary outcomes were postoperative complications, length of hospital stay (LOS) and off-bed time.

RESULTS

A total of 207 patients were included; 95 patients in the pre-ERAS group were compared with 112 patients in the ERAS group. There was no significant difference between the two groups in baseline demographic. Patients in the ERAS group had significantly shorter LOS, bed-off time and earlier drainage tube and catheter removal time. The rate of postoperative complications differed significantly between the pre-ERAS and ERAS groups. Patients in the ERAS group had significantly less intraoperative blood loss, financial cost and opioid consumption than patients in the pre-ERAS group. The VAS and ODI scores, similar at baseline, were significantly lower in the ERAS group at postoperative day 3 (POD 3).

CONCLUSIONS

The benefits of our ERAS protocol for patients undergoing short-level posterior lumbar fusion are evident in terms of reduced hospital stay and time to get out of bed, reduced incidence of postoperative complications, intraoperative blood loss, opioid use and hospital costs, and improved early postoperative pain and dysfunction.

Role of psychosocial factors on the effect of physical activity on physical function in patients after lumbar spine surgery

Background

The purpose of this study was to investigate the longitudinal postoperative relationship between physical activity, psychosocial factors, and physical function in patients undergoing lumbar spine surgery.

Methods

We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition. Physical activity was measured using a triaxial accelerometer (Actigraph GT3X) at 6-weeks (6wk), 6-months (6M), 12-months (12M) and 24-months (24M) following spine surgery. Physical function (computerized adaptive test domain version of Patient-Reported Outcomes Measurement Information System) and psychosocial factors (pain self-efficacy, depression and fear of movement) were assessed at preoperative visit and 6wk, 6M, 12M and 24M after surgery. Structural equation modeling (SEM) techniques were utilized to analyze data, and results are represented as standardized regression weights (SRW). Overall SRW were computed across five imputed datasets to account for missing data. The mediation effect of each psychosocial factor on the effect of physical activity on physical function were computed [(SRW for effect of activity on psychosocial factor X SRW for effect of psychosocial factor on function) ÷ SRW for effect of activity on function]. Each SEM model was tested for model fit by assessing established fit indexes.

Results

The overall effect of steps per day on physical function (SRW ranged from 0.08 to 0.19, p<0.05) was stronger compared to the overall effect of physical function on steps per day (SRW ranged from non-existent to 0.14, p<0.01 to 0.3). The effect of steps per day on physical function and function on steps per day remained consistent after accounting for psychosocial factors in each of the mediation models. Depression and fear of movement at 6M mediated 3.4% and 5.4% of the effect of steps per day at 6wk on physical function at 12M, respectively. Pain self-efficacy was not a statistically significant mediator.

Conclusions

The findings of this study suggest that the relationship between physical activity and physical function is stronger than the relationship of function to activity. However, future research is needed to examine whether promoting physical activity during the early postoperative period may result in improvement of long-term physical function. Since depression and fear of movement had a very small mediating effect, additional work is needed to investigate other potential mediating factors such as pain catastrophizing, resilience and exercise self-efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04622-w.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

OBJECTIVE

To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

SETTING

Secondary care.

PARTICIPANTS

Patients (≥18 years) undergoing major elective surgery (curative or palliative).

INTERVENTIONS

Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

OUTCOMES AND MEASURES

Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

REVIEW METHODS

Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

RESULTS

178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

CONCLUSIONS

Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42015019191.

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review

OBJECTIVE

To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients.

DATA SOURCES

Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020.

STUDY SELECTION

Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study.

DATA EXTRACTION AND SYNTHESIS

Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used.

RESULTS

6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes.

CONCLUSIONS

Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019151475.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Prehabilitation Coming of Age: IMPLICATIONS FOR CARDIAC AND PULMONARY REHABILITATION

While cardiac and pulmonary rehabilitation programs traditionally involve exercise therapy and risk management following an event (eg, myocardial infarction and stroke), or an intervention (eg, coronary artery bypass surgery and percutaneous coronary intervention), prehabilitation involves enhancing functional capacity and optimizing risk profile prior to a scheduled intervention. The concept of prehabilitation is based on the principle that patients with higher functional capabilities will better tolerate an intervention, and will have better pre- and post-surgical outcomes. In addition to improving fitness, prehabilitation has been extended to include multifactorial risk intervention prior to surgery, including psychosocial counseling, smoking cessation, diabetes control, nutrition counseling, and alcohol abstinence. A growing number of studies have shown that patients enrolled in prehabilitation programs have reduced post-operative complications and demonstrate better functional, psychosocial, and surgery-related outcomes. These studies have included interventions such as hepatic transplantation, lung cancer resection, and abdominal aortic aneurysm (repair, upper gastrointestinal surgery, bariatric surgery, and coronary artery bypass grafting). Studies have also suggested that incorporation of prehabilitation before an intervention in addition to traditional rehabilitation following an intervention further enhances physical function, lowers risk for adverse events, and better prepares a patient to resume normal activities, including return to work. In this overview, we discuss prehabilitation coming of age, including key elements related to optimizing pre-surgical fitness, factors to consider in developing a prehabilitation program, and exercise training strategies to improve pre-surgical fitness.

Current Prehabilitation Programs Do Not Improve the Postoperative Outcomes of Patients Scheduled for Lumbar Spine Surgery: A Systematic Review With Meta-analysis

OBJECTIVE

To assess the effectiveness of prehabilitation in patients with degenerative disorders of the lumbar spine who are scheduled for spine surgery.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

Seven electronic databases were systematically searched for randomized controlled trials or propensity-matched cohorts.

STUDY SELECTION CRITERIA

Studies that measured the effect of prehabilitation interventions (ie, exercise therapy and cognitive behavioral therapy [CBT]) on physical functioning, pain, complications, adverse events related to prehabilitation, health-related quality of life, psychological outcomes, length of hospital stay, use of analgesics, and return to work were included.

DATA SYNTHESIS

Data were extracted at baseline (preoperatively) and at short-term (6 weeks or less), medium-term (greater than 6 weeks and up to 6 months), and long-term (greater than 6 months) follow-ups. Pooled effects were analyzed as mean differences and 95% confidence intervals (CIs). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS

Cognitive behavioral therapy interventions were no more effective than usual care for all outcomes. Pooled effect sizes were -2.0 (95% CI: -4.4, 0.4) for physical functioning, -1.9 (95% CI: -5.2, 1.4) for back pain, and -0.4 (95% CI: -4.1, 0.4) for leg pain. Certainty of evidence for CBT ranged from very low to low. Only 1 study focused on exercise therapy and found a positive effect on short-term outcomes.

CONCLUSION

There was very low-certainty to low-certainty evidence of no additional effect of CBT interventions on outcomes in patients scheduled for lumbar surgery. Existing evidence was too limited to draw conclusions about the effects of exercise therapy. J Orthop Sports Phys Ther 2021;51(3):103-114. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9748.

Implementing a behavioral medicine approach in physiotherapy for patients with musculoskeletal pain: a scoping review

Supplemental Digital Content is Available in the Text.

The interventions in the scoping review were in agreement with the definition of behavioral medicine in physiotherapy, but reported behavior change techniques were few.

In intervention research on musculoskeletal pain, physiotherapists often study behavioral and cognitive components. Evidence on applying these components has increased during the past decade. However, how to effectively integrate behavioral and cognitive components in the biopsychosocial management of musculoskeletal pain is challenging. The aim was to study the intervention components and patient outcomes of studies integrating behavioral and cognitive components in physiotherapy, to match the interventions with a definition of behavioral medicine in physiotherapy and to categorize the behavior change techniques targeted at patients with musculoskeletal pain in (1) randomized controlled effect trials or (2) implementation in clinical practice trials. A scoping review was used to conduct this study, and the PRISMA-ScR checklist was applied. Relevant studies were identified from the PubMed, MEDLINE, PsycINFO, CINAHL Plus, and Web of Science Core databases separately for the (1) randomized controlled effect trials and (2) implementation in clinical practice trials. Synthesis for the matching of the patient interventions with the existing definition of behavior medicine in physiotherapy showed that the interventions mostly integrated psychosocial, behavioral, and biomedical/physical aspects, and were thus quite consistent with the definition of behavioral medicine in physiotherapy. The reported behavior change techniques were few and were commonly in categories such as “information of natural consequences,” “feedback and monitoring,” and “goals and planning.” The patient outcomes for long-term follow-ups often showed positive effects. The results of this scoping review may inform future research, policies, and practice.

A randomized controlled TRIal of cognitive BEhavioral therapy for high Catastrophizing in patients undergoing lumbar fusion surgery: the TRIBECA study

Background

Around 20% of patients undergoing spinal fusion surgery have persistent back or leg pain despite surgery. Pain catastrophizing is the strongest psychological predictor for chronic postsurgical pain. Psychological variables are modifiable and could be target for intervention. However, randomized controlled trials evaluating the effectiveness of psychological interventions to reduce chronic pain and disability after spinal fusion in a population of patients with high preoperative pain catastrophizing scores are missing. The aim of our study is to examine whether an intervention targeting pain catastrophizing mitigates the risk of chronic postsurgical pain and disability. Our primary hypothesis is that targeted perioperative cognitive behavioral therapy decreases the risk of chronic postsurgical pain and disability after spinal fusion surgery in high catastrophizing patients.

Methods

We will perform a two-center prospective, single-blind, randomized, controlled study comparing lumbar spinal fusion surgery outcome between 2 cohorts. Adult patients selected for lumbar spinal fusion with decompression surgery and a minimum score of 24 on the pain catastrophizing scale will be randomized with 1:1 allocation for either perioperative cognitive behavioral therapy (intervention group) or a perioperative education plus progressive exercise program (control group). Patients randomized to the intervention group will receive six individual sessions of cognitive behavioral therapy, two sessions before the operation and four after. Primary outcome is the Core Outcome Measures Index at 12 months. Secondary outcomes include pain, disability, depression and quality of life.

Discussion

This is the first trial that evaluates the effectiveness of cognitive behavioral therapy as a perioperative tool to improve pain and disability after spinal fusion surgery in comparison with an educational/exercise control intervention, in patients with high levels of pain catastrophizing. If perioperative cognitive behavioral therapy proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcome after spinal fusion surgery.

Trial registration

Clinicaltrials (NCT03969602). Registered 31 May 2019,

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain (PREVSAM): a randomised controlled trial protocol

BACKGROUND

Musculoskeletal pain is globally a leading cause of physical disability. Many musculoskeletal-related pain conditions, such as low back pain, often resolve spontaneously. In some individuals, pain may recur or persist, leading to ong-term physical disability, reduced work capacity, and sickness absence. Early identification of individuals in which this may occur, is essential for preventing or reducing the risk of developing persistent musculoskeletal pain and long-term sickness absence. The aim of the trial described in this protocol is to evaluate effects of an early intervention, the PREVSAM model, on the prevention of sickness absence and development of persistent pain in at-risk patients with musculoskeletal pain.

METHODS

Eligible participants are adults who seek health care for musculoskeletal pain and who are at risk of developing persistent pain, physical disability, and sickness absence. Participants may be recruited from primary care rehabilitation centres or primary care healthcare centres in Region Västra Götaland. Participants will be randomised to treatment according to the PREVSAM model (intervention group) or treatment as usual (control group). The PREVSAM model comprises an interdisciplinary, person-centred rehabilitation programme, including coordinated measures within primary health care, and may include collaboration with participants' employers. The primary outcome sickness absence is operationalised as the number and proportion of individuals who remain in full- or part-time work, the number of gross and net days of sickness absence during the intervention and follow-up period, and time to first sickness absence spell. Secondary outcomes are patient-reported short-term sickness absence, work ability, pain, self-efficacy, health-related quality of life, risk for sickness absence, anxiety and depression symptoms and physical disability at 1 and 3 months after inclusion (short-term follow-up), and at 6 and 12 months (long-term follow-up). A cost-effectiveness analysis is planned and drug consumption will be investigated.

DISCUSSION

The study is expected to provide new knowledge on the effectiveness of a comprehensive rehabilitation model that incorporates early identification of patients with musculoskeletal pain at risk for development of sickness absence and persistent pain. The study findings may contribute to more effective rehabilitation processes of this large patient population, and potentially reduce sickness absence and costs.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol ID: NCT03913325 , Registered April 12, 2019. Version 2, 10 July 2020. Version 2 changes: Clarifications regarding trial aim and inclusion process.