Lumbar Spine Surgery Outcomes: Physiotherapy, Patient Mood and Behavior
Highlight from the 30th Annual Meeting of the North American Spine Society (NASS) in Chicago
Presented by Matthew Smuck, MD
Matthew Smuck, MD presented The Role of Bracing, Therapy and Psychological Counseling in Managing Postoperative Pain. Dr. Smuck is Chief of Physical Medicine and Rehabilitation, Associate Professor of Orthopaedics at Stanford University, and Medical Director of Rehabilitation for Stanford Healthcare in Redwood City, CA. During his talk, Dr. Smuck related how therapy and counseling may enhance surgical recovery.
“Prolonged pain after surgery has been shown to be influenced by these factors: Patient selection, type of surgery performed, and whether or not there's a postop rehabilitation plan,” stated Dr. Smuck. “The mechanisms for prolonged pain after surgery are mostly theoretical, and they hinge around changes in muscle strength, muscle size, or muscle inhibition, but one area where there's a lot of proof that a mechanism is involved is in maladaptive pain beliefs and mood and behaviors,” Dr. Smuck explained.
Physiotherapy Following Lumbar Disc Surgery
There is very limited evidence about physiotherapy’s role (low-intensity, high-intensity exercise) following lumbar spinal fusion. In one study, a systematic review and meta-analysis combining two randomized trials involving 188 participants, the results were inconclusive.1 Oosterhuis et al investigated active rehabilitation commencing at different times (eg, immediately postop, 4 weeks postop) compared to no treatment, placebo or delayed therapy following lumbar disc surgery. While participants reported reduced pain in exercise programs starting 4-6 weeks after lumbar disc surgery, when compared to no therapy the overall “evidence is only low to very low.”2 Dr. Smuck said, “The point to take home here is not that exercise doesn’t work, it’s that exercise provided in a multimodal approach is an important part of recovery.”
Rehabilitation Following Surgery for Lumbar Spinal Stenosis
McGregor et al pooled and examined data from several trials involving a total of 373 participants. Active rehabilitation versus “usual care” in adults greater than 18 years, diagnosed with lumbar spinal stenosis and who underwent first-time decompressive surgery—with or without fusion—were studied.3 “They concluded that activation rehabilitation is more effective than usual care in improving both short- and long-term functional status,” stated Dr. Smuck. Tompkins-Lane et al designed a self-paced walking study (pedometer) to evaluate 10 overweight patients with lumbar stenosis.4 The investigators “showed that just a 15% increase in the number of steps they take in a day had meaningful and measurable and statistically significant benefits in terms of the disease burden by self-report, and also several objective measures such as fat density,” said Dr. Smuck.
Psychological Counseling and Postoperative Pain
Quoting famous mathematician John W. Tukey, "An approximate answer to the right question is worth a great deal more than a precise answer to the wrong question." Dr. Smuck asked, “Which preop variable has the greatest impact on measured outcomes following surgery in the spine?” The answer is mood. Mood and patient behavior have consistently been shown to have a strong impact on spine surgery outcomes.
Coronado et al investigated pain catastrophizing and its effect on outcomes. Their findings suggest that early screening for certain pain behaviors may identify patients at risk for poor surgical outcomes.5 “If you don't deal with mood and behavior issues preoperatively, then you're asking for worsened outcomes, you're asking for prolonged pain and increased disability,” stated Dr. Smuck.
Two Concluding Suggestions
In conclusion, Dr. Smuck made two suggestions: “Begin to address the mood and maladaptive behaviors before surgery, there are treatments for these things and ways of dealing with them; they can't all be fixed before surgery, but they do need to be addressed, if you wait until after surgery it's too late. And number two, get patients moving after surgery.”