Use of the PREPARE (PREhabilitation, Physical Activity and exeRcisE) program to improve outcomes after lumbar fusion surgery for severe low back pain: a study protocol of a person-centred randomised controlled trial

Long-Term Follow-Up of a Person-Centered Prehabilitation Program Based on Cognitive-Behavioral Physical Therapy for Patients Scheduled for Lumbar Fusion

OBJECTIVE

Long-term follow-ups of prehabilitation programs for lumbar spine surgery are lacking, and more comprehensive evaluations are needed. In the current study, we evaluated the long-term effects of a prehabilitation program compared with conventional care in relation to lumbar fusion surgery in patients with degenerative disc disease.

METHODS

Patients (n = 118) receiving lumbar fusion surgery were included in a multicenter randomized controlled trial, involving 1 university hospital and 2 spine clinics. The intervention was a person-centered prehabilitation program based on cognitive-behavioral physical therapy that targeted psychological presurgical risk factors, physical activity, and overall health. The control group received conventional preoperative care. Patient-reported outcome measures (PROMs) included assessments at 8 time-points: low back disability (primary outcome), back pain intensity, leg pain intensity, pain catastrophizing, fear of movement, anxiety and depressive mood, health-related quality of life, and patient-specific functioning. Physical activity and physical capacity were assessed at 5 time points. Linear mixed models were used to analyze the effects of the intervention.

RESULTS

There were no significant differences between groups at the 12- and 24-month follow-ups for any outcome, except for the One Leg Stand test 1 year following surgery, in favor of the control group. There were significant improvements for both groups, from baseline to the 12- and 24-month follow-ups for all physical capacity test and patient-reported outcome measures, except for leg pain and self-efficacy for exercise.

CONCLUSION

No long-term effects were found for the prehabilitation program compared to conventional care. Physical activity did not improve over time, despite significantly improved self-reported functioning and physical capacity measurements.

IMPACT

These findings have implications for the current understanding of the long-term effects of prehabilitation and suggest that future research should focus on programs promoting physical activity both before and after lumbar spine surgery to decrease the risk of long-term adverse health outcomes.

Implementing a nurse-led prehabilitation program for patients undergoing spinal surgery

ABSTRACT

Prehabilitation, or "prehab," helps patients optimize strength, function, and nutrition before surgery. This evidence-based practice project presents strategies for implementing a prehab program to prepare patients for spinal surgery. Nurses play an integral role in educating patients preoperatively about the myriad lifestyle changes associated with spinal surgery.

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.

ABO blood types may affect transient neurological events after surgical revascularization in patients with moyamoya disease: a retrospective single center study

BACKGROUND

Moyamoya disease (MMD) is a cerebrovascular disease with unknown cause. Patients with MMD disease usually experience transient neurological events (TNEs) after revascularization surgery. This retrospective single-center study was aimed to explore the risk factors of postoperative TNEs after surgical revascularization in patients with MMD.

METHODS

We selected 324 patients who underwent surgical revascularization between January 2017 and September 2022 in our center. The perioperative characteristics of the patients were recorded and the outcome was TNEs after surgery. An analysis of risk factors contributing to postoperative TNEs by using logistic regression model.

RESULTS

Three hundred twelve patients were enrolled, and the incidence of postoperative TNEs was 34% in our study. Males were more likely to suffer from postoperative TNEs (OR = 2.344, p = 0.002). Preoperative ischemic presentation (OR = 1.849, p = 0.048) and intraoperative hypotension (OR = 2.332, p = 0.002) were associated with postoperative TNEs. Compared to patients with blood type O, patients with blood type A (OR = 2.325, p = 0.028), B (OR = 2.239, p = 0.027) and AB (OR = 2.938, p = 0.019) had a significantly higher incidence of postoperative TNEs. A risk prediction model for postoperative TNEs was established, and the established risk prediction area under the receiver operating characteristic curve (ROC) of the model was 0.741.

CONCLUSIONS

Males, preoperative ischemic presentation and intraoperative hypotension were associated with postoperative TNEs. We also found a possible link between postoperative TNEs and ABO blood types after surgical revascularization for moyamoya patients.

Developing Mixed-effects Models to Optimize Prediction of Postoperative Outcomes in a Modern Sample of Over 450,000 Patients Undergoing Elective Cervical Spine Fusion Surgery

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

We utilize big data and modeling techniques to create optimized comorbidity indices for predicting postoperative outcomes following cervical spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Cervical spine decompression and fusion surgery are commonly used to treat degenerative cervical spine pathologies. However, there is a paucity of high-quality data defining the optimal comorbidity indices specifically in patients undergoing cervical spine fusion surgery.

METHODS

Using data from 2016 to 2019, we queried the Nationwide Readmissions Database (NRD) to identify individuals who had received cervical spine fusion surgery. The Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining indicator was used to assess frailty. To measure the level of comorbidity, Elixhauser Comorbidity Index (ECI) scores were queried. Receiver operating characteristic curves were developed utilizing comorbidity indices as predictor variables for pertinent complications such as mortality, nonroutine discharge, top-quartile cost, top-quartile length of stay, and 1-year readmission.

RESULTS

A total of 453,717 patients were eligible. Nonroutine discharges occurred in 93,961 (20.7%) patients. The mean adjusted all-payer cost for the procedure was $22,573.14±18,274.86 (top quartile: $26,775.80) and the mean length of stay was 2.7±4.4 days (top quartile: 4.7 d). There were 703 (0.15%) mortalities and 58,254 (12.8%) readmissions within 1 year postoperatively. Models using frailty+ECI as primary predictors consistently outperformed the ECI-only model with statistically significant P -values for most of the complications assessed. Cost and mortality were the only outcomes for which this was not the case, as frailty outperformed both ECI and frailty+ECI in cost ( P <0.0001 for all) and frailty+ECI performed as well as ECI alone in mortality ( P =0.10).

CONCLUSIONS

Our data suggest that frailty+ECI may most accurately predict clinical outcomes in patients receiving cervical spine fusion surgery. These models may be used to identify high-risk populations and patients who may necessitate greater resource utilization following elective cervical spinal fusion.

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.

Prevalence and factors associated with lumbopelvic pain among pregnant women in their third trimester: a cross-sectional study

Introduction

pregnancy related lumbopelvic pain, which refers to low back pain and pelvic girdle pain, is a common musculoskeletal disorder affecting quality of life. The purpose of this study was to establish the prevalence and the factors associated with lumbopelvic pain among pregnant women in their third trimester.

Methods

four hundred and nineteen pregnant women were included in this institutional-based cross-sectional study. The study was carried out from October 2018 to March 2019 at Kawempe national referral hospital in Uganda. Pregnant women in the third trimester participated in the study. Pregnant women with preexisting backache, a fracture or surgery to the back, hip or pelvic area in the preceding 12 months were excluded. Lumbopelvic pain was defined as low back pain and pelvic girdle pain. Bivariate and multivariable logistic regression were carried out to establish the factors associated with lumbopelvic pain. The presence of lumbopelvic pain was assessed for and diagnosed using the illustrations in the pelvic girdle questionnaire.

Results

the prevalence of pregnancy related lumbopelvic pain was 46% (95% CI: 40.8-50.4). Most women who had pregnancy related lumbopelvic pain experienced lumbar pain. The factors independently associated with pregnancy related lumbopelvic pain (PLPP) were being HIV sero positive [adjusted odds ratio (AOR) 2.25, 95% CI: 1.17-4.35] and having no monthly income (AOR 0.53, 95% CI: 0.30-0.94).

Conclusion

in this study, PLPP is common in women attending antenatal clinic in their third trimester. The factors associated with PLPP were being HIV positive and having no income. In future pregnant women who come for antenatal care with pregnancy related lumbopelvic pain should be given appropriate advice and support.

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).

Development and validation of a point-of-care clinical risk score to predict surgical site infection following open spinal fusion

Background

Surgical site infection (SSI) after open spine surgery increases healthcare costs and patient morbidity. Predictive analytics using large databases can be used to develop prediction tools to aid surgeons in identifying high-risk patients and strategies for optimization. The purpose of this study was to develop and validate an SSI risk-assessment score for patients undergoing open spine surgery.

Methods

The Premier Healthcare Database of adult open spine surgery patients (n = 157,664; 2,650 SSIs) was used to create an SSI risk scoring system using mixed effects logistic regression modeling. Full and reduced multilevel logistic regression models were developed using patient, surgery or facility predictors. The full model used 38 predictors and the reduced used 16 predictors. The resulting risk score was the sum of points assigned to 16 predictors.

Results

The reduced model showed good discriminatory capability (C-statistic = 0.75) and good fit of the model ([Pearson Chi-square/DF] = 0.90, CAIC=25,517) compared to the full model (C-statistic = 0.75, [Pearson Chi-square/DF] =0.90, CAIC=25,578). The risk scoring system, based on the reduced model, included the following: female (5 points), hypertension (4), blood disorder (8), peripheral vascular disease (9), chronic pulmonary disease (6), rheumatic disease (16), obesity (12), nicotine dependence (5), Charlson Comorbidity Index (2 per point), revision surgery (14), number of ICD-10 procedures (1 per procedure), operative time (1 per hour), and emergency/urgent surgery (12). A final risk score as the sum of the points for each surgery was validated using a 1,000-surgery random hold-out (independent from the study cohort) sample (C-statistic = 0.77).

Conclusions

The resulting SSI risk score composed of readily obtainable clinical information could serve as a strong prediction tool for SSI in preoperative settings when open spine surgery is considered.

Measuring Individual Benefits of Medical Treatments Using Longitudinal Hospital Data with Non-Ignorable Missing Responses Caused by Patient Discharge: Application to the Study of Benefits of Pain Management Post Spinal Fusion

Electronic health records (EHR) provide valuable resources for longitudinal studies and understanding risk factors associated with poor clinical outcomes. However, they may not contain complete follow-ups, and the missing data may not be at random since hospital discharge may depend in part on expected but unrecorded clinical outcomes that occur after patient discharge. These non-ignorable missing data requires appropriate analysis methods. Here, we are interested in measuring and analyzing individual treatment benefits of medical treatments in patients recorded in EHR databases. We present a method for predicting individual benefits that handles non-ignorable missingness due to hospital discharge. The longitudinal clinical outcome of interest is modeled simultaneously with the hospital length of stay using a joint mixed-effects model, and individual benefits are predicted through a frequentist approach: the empirical Bayesian approach. We illustrate our approach by assessing individual pain management benefits to patients who underwent spinal fusion surgery. By calculating sample percentiles of empirical Bayes predictors of individual benefits, we examine the evolution of individual benefits over time. We additionally compare these percentiles with percentiles calculated with a Monte Carlo approach. We showed that empirical Bayes predictors of individual benefits do not only allow examining benefits in specific patients but also reflect overall population trends reliably.

The duration of chronic low back pain is associated with acute postoperative pain intensity in lumbar fusion surgery: a prospective observational study

BACKGROUND

Pre-existing chronic pain has been associated with severe postoperative pain. In this study, we sought to prospectively analyse the association between the duration of chronic low back pain and the intensity of acute postoperative pain after lumbar fusion surgery.

METHODS

A total of 330 patients who underwent lumbar fusion surgery were divided into three groups (chronic low back pain less than 1 year, one to 5 years, and more than 5 years) based on the duration of chronic pain. On the first postoperative day, the maximum pain scores of each patient were recorded during the day and at night. Bivariate correlation and logistic regression were performed to identify relationships between acute postoperative pain and related variables (age, sex, smoking history, body mass index, operation history, duration of surgery, level of preoperative pain, aetiology of back pain, Self-rating Anxiety Scale, Self-rating Depression Scale, FRAIL scale, and duration of chronic low back pain). If the postoperative pain score was > 3 when the patient reported was at rest, the patients were treated with postoperative intravenous self-controlled analgesia or rescue analgesics if necessary.

RESULTS

There was an association between severe acute postoperative pain and the duration of chronic low back pain. In terms of VAS day, multivariable logistic regression showed the duration of chronic low back pain was not statistically significant (OR = 2.48, 95% CI: 0.900 to 6.828, p = 0.0789). The result is uncertain because the confidence interval included the null after controlling for SAS, SDS, BMI, and aetiology of back pain. In terms of VAS night, patients with a duration of chronic low back pain of more than 5 years were more likely having moderate to severe acute postoperative pain (VAS > 3) compared to patients with a duration of chronic low back pain less than 1 year (OR = 3.546, 95% CI: 1.405 to 8.95, p = 0.0074). Hospital stay, the pain score on the day of discharge and the pain score after 3 months displayed no significant difference among the three groups (P > 0.05). However, the need for postoperative rescue analgesics was different among the three groups (P < 0.05).

CONCLUSION

The longer the duration of chronic pain was, the higher the incidence of moderate to severe acute postoperative pain was and the greater the amount of analgesics required after surgery.

TRIAL REGISTRATION

This study was registered at the Chinese Clinical Trial Registration Center ( http://www.chictr.org.cn/index.aspx , clinical trial number: ChiECRCT20200165, date of registration: July 6, 2020).

Factors Associated with Pain Intensity and Walking Disability After Lumbar Fusion: A Longitudinal Study

STUDY DESIGN

Retrospective longitudinal study.

OBJECTIVE

To identify the preoperative factors associated with postoperative lumbar fusion recovery in back or leg pain, self-reported walking time, and gait speed over a 6-month period.

SUMMARY OF BACKGROUND DATA

The demand for lumbar fusion surgeries has significantly increased over the years. Yet, some patients report persistent postsurgical pain and poor functional outcomes. Unfortunately, the associated risk factors are not well understood.

METHODS

The study analyzed 232 subjects with mono- or bisegmental lumbar fusion surgery who underwent standardized assessment preoperatively and at 4, 12, and 24weeks postoperatively. Preoperative variables collected were demographic, clinical, and psychological variables. Back or leg pain was measured by the Numeric Pain Rating Scale. Walking disability was measured by self-reported walking time and performance-based fast gait speed. Risk factors of pain and walking disability over time were identified using ordinal and linear mixed-effects modeling.

RESULTS

At 6 months post-surgery, 17% of patients reported having moderate or severe back/leg pain and 24% were unable to walk longer than 30 minutes. Greater preoperative self-reported leg weakness frequency and body-mass-index (BMI) were strongly associated with greater pain and walking disability. Additionally, greater preoperative depression symptoms were associated with greater back/leg pain (adjusted odds ratio = 4.0) and shorter walking time (adjusted odds ratio = 2.7)-but not with slower gait speed (difference = 0.01 m/s). Old age and female gender were strongly associated with gait speed but not with self-reported walking time.

CONCLUSION

A sizable proportion of patients had poor pain and walking outcomes even at 6 months post-surgery. Preoperative leg weakness and BMI were consistent risk factors and patients with greater depression symptoms may have poorer self-reported outcomes. Although requiring validation, our study has identified potentially modifiable risk factors which may give clinicians an opportunity to provide early (preoperative) and targeted intervention strategies to optimize postoperative outcomes.

Level of Evidence: NA.

Impact of a Perioperative Protocol on Length of ICU and Hospital Stay in Complex Spine Surgery

BACKGROUND

In an attempt to improve patient care, a perioperative complex spine surgery management protocol was developed through collaboration between spine surgeons and neuroanesthesiologists. The aim of this study was to investigate whether implementation of the protocol in 2015 decreased total hospital and intensive care unit (ICU) length of stay (LOS) and complication rates after elective complex spine surgery.

MATERIALS AND METHODS

A retrospective cohort study was conducted by review of the medical charts of patients who underwent elective complex spine surgery at an academic medical center between 2012 and 2017. Patients were divided into 2 groups based on the date of their spine surgery in relation to implementation of the spine surgery protocol; before-protocol (January 2012 to March 2015) and protocol (April 2015 to March 2017) groups. Outcomes in the 2 groups were compared, focusing on hospital and ICU LOS, and complication rates.

RESULTS

A total of 201 patients were included in the study; 107 and 94 in the before-protocol and protocol groups, respectively. Mean (SD) hospital LOS was 14.8±10.8 days in the before-protocol group compared with 10±10.7 days in the protocol group (P<0.001). The spine surgery protocol was the primary factor decreasing hospital LOS; incidence rate ratio 0.78 (P<0.001). Similarly, mean ICU LOS was lower in the protocol compared with before-protocol group (4.2±6.3 vs. 6.3±7.3 d, respectively; P=0.011). There were no significant differences in the rate of postoperative complications between the 2 groups (P=0.231).

CONCLUSION

Implementation of a spine protocol reduced ICU and total hospital LOS stay in high-risk spine surgery patients.

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,

Mechanical detection and pain thresholds: comparability of devices using stepped and ramped stimuli

Nylon monofilaments may substitute for German Research Network on Neuropathic Pain standards in tactile but not pinprick testing. Ramped stimuli are faster but underestimate thresholds due to reaction time artefacts.

Quantitative sensory testing is used to assess somatosensory function in humans. The protocol of the German Research Network on Neuropathic Pain (DFNS) provides comprehensive normative values using defined tools; however, some of these may not be feasible in low-resource settings.

Rehabilitation in adult spinal deformity

Adult spinal deformity causes significant health-related problems such as pain and disability in adults. Currently, there are several non-operative management strategies such as pain medications, physical modalities, exercises, bracing or interventional procedures. Specific exercises including strengthening of back and abdominal muscles, neuromuscular re-education for daily tasks, and active self-correction are vital to improve postural control and spinal stability. Bracing for a few hours a day can help reduce pain and provide spinal stability in adults. In case of severe disability and pain unresponsive to non-operative treatments, spinal fusion with instrumentation is an alternative. Postoperative rehabilitation can help to reduce pain and disability and improve return to activity or work. Protecting the spine early after surgery and timing of initiation of exercises with respect to osseointegration and bone remodeling phases are important principles of postoperative rehabilitation. In this review, rehabilitation in adult spinal deformity is discussed in the light of the literature.

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

BACKGROUND

Prehabilitation programs have led to improved postoperative outcomes in several surgical contexts, but there are presently no guidelines for the prehabilitation phase before lumbar fusion surgery.

OBJECTIVE

The objective was to investigate whether a person-centered physical therapy prehabilitation program, based on a cognitive-behavioral approach, is more effective than conventional care in reducing disability and improving functioning after lumbar fusion surgery in patients with degenerative disk disease.

DESIGN

This study was a randomized controlled trial.

SETTING

The study took place at 2 private spine clinics and 1 university hospital.

PATIENTS

We prospectively enrolled 118 patients scheduled for lumbar fusion surgery.

INTERVENTION

The active intervention used a person-centered perspective and focused on promoting physical activity and targeting psychological risk factors before surgery. The control group received conventional preoperative care.

MEASUREMENTS

The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on 6 occasions up to 6 months postoperatively. A linear mixed model was used to analyze the change scores of each outcome.

RESULTS

No statistically significant between-group difference was found on the primary outcome (disability) over time (baseline to 6 months). Among secondary outcome measures, a statistically significant interaction effect ("Group × Time") was seen for the European Quality of Life 5 Dimensions Questionnaire. The largest between-group difference on the European Quality of Life 5 Dimensions Questionnaire index was seen 1 week prior to surgery and favored the active intervention. The largest between-group effect sizes at the 6-month follow-up favored the active intervention, and were seen for physical activity intensity, steps per day, and the One Leg Stand Test. Both groups reached the minimal important change for the primary outcome and, in several secondary outcomes (pain intensity, back and leg; pain catastrophizing; anxiety; health-related quality of life [EQ5D VAS]), already at 8-week follow-up.

LIMITATIONS

The participants' preoperative level of disability was lower than normative values, which suggests selection bias.

CONCLUSIONS

Both interventions led to clinically important changes, but it is not clear what kind of prehabilitation program is the most effective.

One-minute stair climbing, 50-foot walk, and timed up-and-go were responsive measures for patients with chronic low back pain undergoing lumbar fusion surgery

Background

Physical capacity tasks are useful tools to assess functioning in patients with low back pain (LBP), but evidence is scarce regarding the responsiveness (ability to detect change over time) and minimal important change (MIC). The aim was to investigate the responsiveness and MIC of 5-min walk, 1-min stair climbing, 50-ft walk, and timed up-and-go in patients with chronic LBP undergoing lumbar fusion surgery.

Methods

In this clinimetric study, 118 patients scheduled for lumbar fusion surgery for motion-elicited chronic LBP with degenerative changes were included. All patients performed the physical capacity tasks 5-min walk, 1-min stair climbing, 50-ft walk, and timed up-and-go 8–12 weeks before and six months after surgery. Responsiveness was evaluated by testing five a priori responsiveness hypotheses. The hypotheses concerned the area under the receiver operating characteristics (ROC) curve and correlations (Spearman’s rho) between the change scores of the physical capacity tasks, the Oswestry Disability Index 2.0 (ODI), and back pain intensity measured with visual analog scale (VAS). At least 80% of the hypotheses would have to be confirmed for adequate responsiveness. Absolute and relative MICs for improvement were determined by the optimal cut-off point of the ROC curve based on the classification of improved and unchanged patients according to construct-specific global perceived effect (GPE) scales.

Results

One-minute stair climbing, 50-ft walk and timed up-and-go displayed adequate responsiveness (≥ 80% of hypotheses confirmed), while 5-min walk did not (40% of hypotheses confirmed). The absolute MICs for improvement were 45.5 m for 5-min walk, 20.0 steps for 1-min stair climbing, − 0.6 s for 50-ft walk, and − 1.3 s for timed up-and-go.

Conclusions

The results of responsiveness for 1-min stair climbing, 50-ft walk, and timed up-and-go implies that these have the ability to detect changes in physical capacity over time in patients with chronic LBP who have undergone lumbar fusion surgery.

Patients with severe low back pain exhibit a low level of physical activity before lumbar fusion surgery: a cross-sectional study

BACKGROUND

People with severe low back pain are at higher risk of poor health. Patients scheduled for lumbar fusion surgery are assumed to have low levels of physical activity, but few data exist. The aim of the study was firstly to investigate preoperative levels of objectively measured physical activity in patients with severe low back pain waiting for lumbar fusion surgery, and secondly to investigate whether factors in the fear-avoidance model were associated with these levels.

METHODS

We included 118 patients waiting for lumbar fusion surgery (63 women and 55 men; mean age 46 years). Physical activity expressed as steps per day and total time spent in at least moderate-intensity physical activity was assessed with ActiGraph GT3X+ accelerometers. The data were compared to the WHO recommendations on physical activity for health. Whether factors in the fear-avoidance model were associated with physical activity was evaluated by two different multiple linear regression models.

RESULTS

Ninety-six patients (83%) did not reach the WHO recommendations on physical activity for health, and 19 (16%) patients took fewer than 5000 steps per day, which indicates a sedentary lifestyle. On a group level, higher scores for fear of movement and disability were associated with lower numbers of steps per day.

CONCLUSION

A high proportion of the patients did not reach the WHO recommendations on physical activity and are therefore at risk of poor health due to insufficient physical activity. We also found a negative association between both fear of movement and disability, and the number of steps per day. Action needs to be taken to motivate patients to be more physically active before surgery, to improve health postoperatively. There is a need for interventions aimed at increasing physical activity levels and reducing barriers to physical activity in the prehabilitation phase of this patient group.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN 17115599 , retrospectively Registered 18 may 2015.

Spinal Surgeons' Opinions on Pre- and Postoperative Rehabilitation in Patients Undergoing Lumbar Spinal Fusion Surgery: A Survey-Based Study in the Netherlands and Sweden

STUDY DESIGN

A cross-sectional survey in the Netherlands and Sweden.

OBJECTIVE

To investigate Dutch and Swedish spinal surgeons' opinions on spinal fusion pre- and postoperative rehabilitation.

SUMMARY OF BACKGROUND DATA

Lumbar spinal fusion surgery is increasingly provided in patients with chronic low back pain. No guidelines however exist for pre- and postoperative rehabilitation and it is unknown what opinions spinal surgeons currently have about pre- and postoperative rehabilitation.

METHODS

A survey was circulated to Dutch and Swedish spinal surgeons. Reminders were sent after 4 and 8/9 weeks. Data of completed questionnaires of orthopedic- and neurosurgeons currently performing lumbar spinal fusion were included for analysis. Analysis comprised a range of descriptive summaries (numerical, graphical, and tabular).

RESULTS

Surveys of 34 Dutch and 48 Swedish surgeons were analyzed. Surgeons provided preoperative information on postoperative mobilization. Spinal fusion techniques varied, but technique did not influence postoperative treatment. Swedish surgeons recommended slightly faster mobilization than Dutch (direct vs. 1-day postoperative), and more activities the first day (sitting, standing, walking). Stair climbing was the most reported discharge criterion; however, time point to start varied. More Swedish surgeons referred to postoperative physiotherapy than Dutch (88% vs. 44%). Time-point to start home activities varied from 1 week to more than 6 months. Pain increase was allowed for less than 24 hours (The Netherlands 81%, Sweden 92%).

CONCLUSION

Findings reflect variability in lumbar spinal fusion rehabilitation in two European countries, especially in postoperative phase. The study proposes many new research topics and acts as starting point for future research valuable for the spinal community.

LEVEL OF EVIDENCE

3.

Does a Program Based on Cognitive Behavioral Therapy Affect Kinesiophobia in Patients Following Total Knee Arthroplasty? A Randomized, Controlled Trial With a 6-Month Follow-Up

BACKGROUND

To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).

METHODS

This was a parallel-group, randomized, controlled pilot study in which 100 patients who exhibited kinesiophobia after TKA were randomly assigned to participate in a CBT (experimental group) or standard care (control group) program. Each group included 50 patients. Before intervention (preintervention), 4 weeks after intervention (postintervention), and 6 months after the end of intervention (follow-up), patients were assessed via the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a numerical rating scale, and the Hospital for Special Surgery knee rating scale. Repeated-measures analysis of variance was used to test the significance of each outcome measure.

RESULTS

The CBT program had significant group (P < .001), time (P < .001), and group-by-time interaction (P < .001) effects on kinesiophobia, pain catastrophizing, and knee function, and these effects lasted for at least 6 months after the end of the intervention. Pain was reduced in both groups after the intervention, but there were significant time and group effects (P = .003) in favor of the experimental group.

CONCLUSION

The CBT program was superior to standard care in reducing kinesiophobia, pain catastrophizing, and knee pain and in enhancing knee function in patients who have a high level of kinesiophobia following TKA. The treatment effect was clinically significant and lasted for at least 6 months after the end of the intervention.

Pre-optimization of spinal surgery patients: Development of a neurosurgical enhanced recovery after surgery (ERAS) protocol

OBJECTIVE

Despite surgical, technological, medical, and anesthetic improvements, patient outcomes following elective neurosurgical procedures can be associated with high morbidity. Enhanced recovery after surgery (ERAS) protocols are multimodal care pathways designed to optimize patient outcomes by addressing pre-, peri-, and post-operative factors. Despite significant data suggesting improved patient outcomes with the adoption of these pathways, development and implementation has been limited in the neurosurgical population.

METHODS/RESULTS

This study protocol was designed to establish the feasibility of a randomized controlled trial to assess the efficacy of implementation of an ERAS protocol on the improvement of clinical and patient reported outcomes and patient satisfaction scores in an elective inpatient spine surgery population. Neurosurgical patients undergoing spinal surgery will be recruited and randomly allocated to one of two treatment arms: ERAS protocol (experimental group) or hospital standard (control group). The experimental group will undergo interventions at the pre-, peri-, and post-operative time points, which are exclusive to this group as compared to the hospital standard group.

CONCLUSIONS

The present proposal aims to provide supporting data for the application of these specific ERAS components in the spine surgery population and provide rationale/justification of this type of care pathway. This study will help inform the design of a future multi-institutional, randomized controlled trial.

RESULTS

of this study will guide further efforts to limit post-operative morbidity in patients undergoing elective spinal surgery and to highlight the impact of ERAS care pathways in improving patient reported outcomes and satisfaction.

Long-Term Pain and Recovery After Major Pediatric Surgery: A Qualitative Study With Teens, Parents, and Perioperative Care Providers

Research developing targeted treatment focused on coping with children's long-term pain after surgery is needed because of the high prevalence of chronic pain after surgery. This qualitative study aimed to: 1) understand the child's and family's experiences of pain over the course of their surgical experience, and 2) gather stakeholder input regarding potential barriers and facilitators of perioperative intervention delivery. Fifteen children ages 10 to 18 years who underwent recent major surgery, their primary caregivers, and 17 perioperative health care providers were interviewed. Interviews were coded using semantic thematic analysis. The perioperative period presented emotional challenges for families. Families felt unprepared for surgery and pain. Recovery and regaining physical functioning at home was challenging. Families struggled to return to valued activities. Families reported interest in a perioperative psychosocial intervention. Providers endorsed that families would benefit from enhanced coping skills. They emphasized that families would benefit from more detailed preparatory information. Providers suggested that flexible intervention delivery at home would be ideal. Research developing interventions addressing pain and anxiety in children undergoing major surgery is critically needed. The findings of the present study can inform intervention development with the aim of improving short- as well as long-term recovery in children undergoing major surgery.

PERSPECTIVE

This qualitative study examined children and their parents' experience of long-term pain and recovery after major surgery, identifying barriers and facilitators of perioperative intervention delivery. Families experienced surgery as stressful, and felt underprepared for pain and recovery. Families and health care providers expressed interest in a preoperative intervention teaching coping skills.