Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial

Abstract

Objective: To evaluate the outcome after spinal surgery when adding prehabilitation to the early rehabilitation.

Design: A randomized clinical study.

Setting: Orthopaedic surgery department.

Subject: Sixty patients scheduled for surgery followed by inpatient rehabilitation for degenerative lumbar disease.

Interventions: The patients were computer randomized to prehabilitation and early rehabilitation (28 patients) or to standard care exclusively (32 patients). The intervention began two months prior to the operation. The prehabilitation included an intensive exercise programme and optimization of the analgesic treatment. Protein drinks were given the day before surgery. The early postoperative rehabilitation included balanced pain therapy with self-administered epidural analgesia, doubled intensified mobilization and protein supplements.

Main measures: The outcome measurements were postoperative stay, complications, functionality, pain and satisfaction.

Results: At operation the intervention group had improved function, assessed by Roland Morris Questionnaire (P = 0.001). After surgery the intervention group reached the recovery milestones faster than the control group (1—6 days versus 3—13, P =0.001), and left hospital earlier (5 (3—9) versus 7 (5—15) days, P =0.007). There was no difference in postoperative complications, adverse events, low back pain and radiating pain, timed up and go, sit-to-stand or in life quality. Patient satisfaction was significantly higher in the intervention group compared with the control group.

Conclusion: The integrated programme of prehabilitation and early rehabilitation improved the outcome and shortened the hospital stay — without more complications, pain or dissatisfaction.

Get full access to this article

View all access options for this article.

References

Deyo RA , Gray DT , Kreuter W. , Mirza S. , Martin BI United States trends in lumbar fusion surgery for degenerative conditions . Spine 2005; 30: 1441-45.

Weinstein JN , Lurie JD , Tosteson TD et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007; 356: 2257-70.

Resnick DK , Choudhri TF , Dailey AT et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 1-17. J Neurosurg Spine 2005; 2: 637-38.

Martin BI , Mirza SK , Comstock BA , Gray DT , Kreuter W. , Deyo RA Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 2007; 32: 382-87.

Langelotz C. , Spies C. , Muller JM , Schwenk W. ‘Fast-track’-rehabilitation in surgery, a multimodal concept. Acta Chir Belg 2005; 105: 555-59.

Kehlet H. Fast-track colonic surgery: status and perspectives. Recent Results Cancer Res 2005; 165: 8-13.

Kehlet H. , Wilmore DW Fast-track surgery. Br J Surg 2005 ; 92: 3-4.

Carli F. , Zavorsky GS Optimizing functional exercise capacity in the elderly surgical population . Curr Opin Clin Nutr Metab Care 2005; 8: 23-32.

Tonnesen H. , Nielsen PR , Lauritzen JB , Moller AM Smoking and alcohol intervention before surgery: Evidence for best practice . Br J Anaesth 2009; 102: 297-306.

10.

Siggeirsdottir K. , Olafsson O. , Jonsson H. , Iwarsson S. , Gudnason V. , Jonsson BY Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement: randomized study of 50 patients with 6 months of follow-up . Acta Orthop 2005; 76: 555-62.

11.

Kehlet H. , Dahl JB Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362: 1921-28.

12.

Sackett DL , Gent M. Controversy in counting and attributing events in clinical trials . N Engl J Med 1979; 301: 1410-12.

13.

Gartlehner G. , Hansen RA , Nissman D. , Lohr KN , Carey TS A simple and valid tool distinguished efficacy from effectiveness studies. J Clin Epidemiol 2006; 59: 1040-48.

14.

Klepstad P. , Loge JH , Borchgrevink PC , Mendoza TR , Cleeland CS , Kaasa S. The Norwegian brief pain inventory questionnaire: translation and validation in cancer pain patients. J Pain Symptom Manage 2002; 24: 517-25.

15.

Albert HB , Jensen AM , Dahl D. , Rasmussen MN [Criteria validation of the Roland Morris questionnaire. A Danish translation of the international scale for the assessment of functional level in patients with low back pain and sciatica]. Ugeskr Laeger 2003; 165: 1875-80.

16.

Roland M. , Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire . Spine 2000; 25: 3115-24.

17.

Simmonds MJ , Olson SL , Jones S. et al. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine 1998; 23: 2412-21.

18.

Sintonen H. The 15D instrument of health-related quality of life: properties and applications . Ann Med 2001; 33: 328-36.

19.

Sintonen H. An approach to measuring and valuing health states. Soc Sci Med [Med Econ] 1981; 15: 55-65.

20.

Kehlet H. , Wilmore DW Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630-41.

21.

Healy WL , Ayers ME , Iorio R. , Patch DA , Appleby D. , Pfeifer BA Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome . J Arthroplasty 1998; 13: 266-76.

22.

Scranton PE , Jr. The cost effectiveness of streamlined care pathways and product standardization in total knee arthroplasty. J Arthroplasty 1999; 14: 182-86.

23.

Kehlet H. Future perspectives and research initiatives in fast-track surgery . Langenbecks Arch Surg 2006; 391: 495-98.

24.

Gonzalez-Castro A. , Shetty A. , Nagendar K. , Greenough CG Day-case conventional discectomy: a randomised controlled trial. Eur Spine J 2002; 11: 67-70.

25.

Brox JI , Reikeras O. , Nygaard O. et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006; 122: 145-55.

26.

Brox JI , Sorensen R. , Friis A. et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003; 28: 1913-21.

27.

Rooks DS , Huang J. , Bierbaum BE et al. Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis Rheum 2006; 55: 700-708.

28.

Petersen MK , Madsen C. , Andersen NT , Soballe K. Efficacy of multimodal optimization of mobilization and nutrition in patients undergoing hip replacement: a randomized clinical trial. Acta Anaesthesiol Scand 2006; 50: 712-17.

29.

Rodgers JA , Garvin KL , Walker CW , Morford D. , Urban J. , Bedard J. Preoperative physical therapy in primary total knee arthroplasty. J Arthroplasty 1998; 13: 414-21.

30.

Ackerman IN , Bennell KL Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic review . Aust J Physiother 2004; 50: 25-30.

31.

Silvasti M. , Pitkanen M. Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty. Acta Anaesthesiol Scand 2001; 45: 471-76.

32.

van der Vyver M. , Halpern S. , Joseph G. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis . Br J Anaesth 2002; 89: 459-65.

33.

Andersen B. Methodological errors in medical research . Oxford, Blackwell Scientific , 1990.

34.

Per Rotbøll Nielsen , Åsa Rudin , Mads U.Werner. Prediction of postoperative pain. Curr Anaesth Crit Care 2007; 18: 157-65.

35.

Kalkman CJ , Visser K. , Moen J. , Bonsel GJ , Grobbee DE , Moons KG Preoperative prediction of severe postoperative pain. Pain 2003; 105: 415-23.

36.

Nielsen PR , Andreasen J. , Asmussen A. , Tønnesen H. Costs and quality of life for fast tracking spine surgery. BMC Health Serv Res 2008; 8: 209.

37.

Christensen FB , Laurberg I. , Bunger CE Importance of the back-cafe concept to rehabilitation after lumbar spinal fusion: a randomized clinical study with a 2-year follow-up . Spine 2003 ; 28: 2561-69.

38.

Soegaard R. , Christensen FB , Lauerberg I. , Bunger CE Lumbar spinal fusion patients’ demands to the primary health sector: evaluation of three rehabilitation protocols. A prospective randomized study. Eur Spine J 2006; 15: 648-56.

39.

Nuelle DG , Mann K. Minimal incision protocols for anesthesia, pain management, and physical therapy with standard incisions in hip and knee arthroplasties: the effect on early outcomes. J Arthroplasty 2007; 22: 20-25.

40.

Roland M. , Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983; 8: 141-44.