Purpose: The primary purpose was to analyse the short and long term effectiveness of physiotherapeutic rehabilitation programs performed during the first 3 month after lumbar fusion surgery. A secondary purpose was to analyse factors predicting long-term disability, back pain and health related quality of life (HRQOL) outcomes after lumbar fusion.
Relevance: The study provides evidence for the effectiveness of early physiotherapy after lumbar fusion. Furthermore improved knowledge of predictive factors can help physiotherapist in the screening of lumbar fusion candidates and the individualised implementation of pre-surgical and post-surgical interventions.
Participants: A total of 107 patients were recruited from the Karolinska University Hospital's Orthopaedic Clinic, Stockholm, Sweden. The inclusion criteria were: men and women aged between 18 and 65 years with a >12 month history of back pain and/or sciatica; a primary diagnosis of spinal stenosis, degenerative or isthmic spondylolisthesis or degenerative disc disease; selected for lumbar fusion with or without decompression; competence in the Swedish language. The criteria for exclusion were: previous lumbar fusion, rheumatoid arthritis and ankylosing spondylitis.
Methods: An open book randomised controlled trial with pre-surgical and post-surgical measures at 3, 6, 12 and 24-36 months was performed to investigate the effectiveness of a psychomotor therapy focusing on cognition, behaviour and motor relearning compared to exercise therapy focusing on strength and conditioning, applied during the first 3 months after lumbar fusion. Randomisation allocated 53 patients to psychomotor therapy and 54 patients to exercise therapy. The Oswestry disability index (ODI) was the primary outcome measure. Secondary measures included the Visual analogue scale for back pain (VAS), European quality of life questionnaire (EQ5D), as well as other clinical, psychological and work related variables.
Analysis: A total of 78 patients were needed assuming a power = 80%. Patient compliance was analysed and an intention to treat principle applied to data analysis. For statistical comparison between the 2 independent groups, analysis of covariance was used. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate pre-surgical predictor variables and address predictive model validity.
Results: Follow-up rates were 93% at 12 months and 81% at 24-36 months after surgery. Psychomotor therapy improved functional disability, self-efficacy, outcome expectancy and fear of movement/(re)injury significantly more than exercise therapy at respective follow-up occasions. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical lasegue test significantly predicted back pain. The implementation of post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL.
Conclusions: The study shows that post-operative rehabilitation can be safely implemented during the first 3 months after lumbar fusion and should include measures to modify psychological as well as motor functions. The study also demonstrates the importance of pre-surgical psychological factors, leg pain intensity, the lasegue test and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL related outcomes.
Implications: Physiotherapist should screen patients pain, psychological factors and neuromusculoskeletal system pre-surgically and rehabilitate patients with early psychomotor therapy after lumbar fusion.