Review Examines the Role and Disparities of Rehabilitation After Lumbar Fusion

Starting physical therapy later and incorporating psychosocial elements have support.

Researchers conducted a systematic review of the current literature on rehabilitation after lumbar fusion surgery and found general support for a formal postoperative rehabilitation program. However, varying opinions about what constitutes rehabilitation exist. As a starting point toward standardization, the review served as the basis for a rehabilitation protocol that is currently undergoing prospective analysis.

“While the data is not yet robust, we can conclude that most patients will benefit from rehabilitation after lumbar fusion surgery,” said Eeric Truumees, MD, Chief Executive Officer at Seton Brain and Spine Institute and Professor at Dell Medical School at the University of Texas in Austin, Texas, and one of the authors of the review.

The review revealed rehabilitative elements with greater odds of success for patients undergoing lumbar fusion, such as aerobic exercise, core strengthening, range of motion optimization, psychosocial interventions, and patient education. Modalities that didn’t have as much support were heat and ice, TENS, and nerve glides.
Group of women in an exercise class doing sit-ups "We can conclude that most patients will benefit from rehabilitation after lumbar fusion surgery”Rehab After Fusion: Some Surprising Findings
Using multiple electronic databases, the authors carefully screened prospective literature using inclusion/exclusion criteria. Then, two authors analyzed the studies (a third author resolved disagreements). After the initial screening, the authors reviewed 21 articles with I or II evidence levels.

Based on the literature review, the authors recommended the following modalities specific to lumbar fusion surgery rehabilitation:

  1. Cardiovascular exercise
  2. Soft-tissue mobilization
  3. Nerve mobilization
  4. Motor control and strengthening
  5. Joint mobilization
  6. Patient education

While the current review focused specifically on postfusion rehabilitation, the authors extrapolated recommendations (where appropriate) to other spine procedures, such as discectomy.

“While the extent of rehabilitation needed may vary based on a patient’s preoperative functional status and their functional goals, the benefits likely extend to patients undergoing less invasive fusion approaches as well,” Dr. Truumees says.

While the research team wasn’t surprised that the existing literature generally supports formal rehabilitation after lumbar fusion surgery, the review yielded some unexpected findings.

First, the authors found that postoperative rehabilitation means different things to different practitioners—both in the literature review and the study group itself.

“We found significant differences in what was considered ‘rehabilitation’ in the published literature,” Dr. Truumees says, who also noted that their postfusion rehab study group was multidisciplinary. “We also found internal differences in our group in how this process was viewed and the terminology employed.”

Secondly, the authors found that starting physical therapy later—at 12 weeks as opposed to 6 weeks postoperatively—delivered better results.

“Our null hypothesis—that early rehabilitation was better than delayed—did not hold up,” Dr. Truumees says. “While early mobilization and ambulation are a good idea, more aggressive core strengthening and range of motion exercises should wait until 12 weeks, in most cases.”

A Look at What’s Next
The findings of this review formed the foundation of a postfusion rehabilitation protocol, which Dr. Truumees says has enough flexibility to account for patient differences, but focuses on key aspects of rehabilitation and de-emphasizes those modalities that had less literature support.

The protocol is currently undergoing a prospective study.

“We hope to have a better sense of optimal timing and elements of rehabilitation in different patient groups,” he says.

Dr. Truumees is also observing what surgeons in other countries are doing to improve the rehabilitation experience and patient outcomes. European practitioners are a model, he says, for their focus on holistic health.

“The best studies on postfusion rehabilitation come from Europe, where the physical aspects of therapy are combined with psychosocial supports,” Dr. Truumees says.

He provides an example known as the “Back Café” model, which places people recovering from similar problems together as a support and exercise group.

“Those approaches also emphasize cognitive and behavioral therapies to decrease fear avoidance and anxiety,” Dr. Truumees says. “It would be great to have similar supports available to our patients, and we are trying to build them.”

In the meantime, Dr. Truumees says that spine surgeons can think beyond the surgical level when helping their patients rehabilitate.

“While a spine surgery may focus on the L4-L5 level, for example, the rehabilitation from that surgery should include the whole patient—mind and body,” he says. “When possible, including their loved ones or other social supports will improve outcomes.”

Updated on: 02/08/18
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