Kyle Mombell, MD, Sean M. Wade, MD, and Patrick Morrissey, MD
Lumbar fusion procedures have dramatically increased in number over the last 2 decades with epidemiologic studies citing a 356% increase from 1993 to 2001 and doubling from 1999 to 2011.1,2 Costs associated with these procedures have also increased significantly. In light of these increasing costs, postoperative physical therapy has garnered appropriate scrutiny with regard to its necessity following lumbar fusion. Rehabilitation regimens remain commonplace but are not often uniform and a relative scarcity of high-level evidence exists to guide treatment. However, the available research favors formal postoperative rehabilitation to improve strength, range of motion, cardiovascular endurance, and patient education,3 and we support its routine use following lumbar spinal fusion.
Instrumented lumbar spinal fusion provides a stable construct that allows early patient mobilization to occur safely. Unfortunately, because of the pain and anxiety that often accompany surgical intervention, many patients are hesitant to move following their procedure. Physical therapy plays an important role both in the immediate in-hospital postoperative phase as well as the acute rehabilitation period. Therapy protocols encourage early physical activity, providing reassurance, teaching transfer techniques, and promoting neutral spine control exercises to assist patients in their recovery. Typically, rehabilitation following lumbar fusion surgery is divided into 3 phases. The first phase begins in the hospital and focuses on basic mobilization and weight bearing activities such as sitting, transfers, and ambulation. The second phase involves outpatient or home-based rehabilitation exercises which emphasize conditioning and strengthening of the core musculature. Finally, the third phase is designed around specific return-to-work rehabilitative interventions. Despite the recognized value of postoperative physical therapy in lumbar fusion surgery, no “gold standard” rehabilitation protocol has been defined in the literature. Perhaps not surprisingly, there is a wide divergence among practitioners in the types of rehabilitative services used and the timing of such treatment relative to surgery.3
Preoperative and postoperative cardiovascular exercise has been shown to decrease length of stay and improve patient-reported outcome scores postoperatively.4 Ambulation is the most common form of cardiovascular exercise utilized, but stationary bicycle and aquatic therapy have roles as well. These forms of generalized aerobic exercise have been shown to decrease pain and increase function at least in the short term after surgery, with a randomized trial with regard to early rehabilitation showing statistically and clinically significant improvements in Oswestry Disability Index (ODI) scores for patients engaged in early rehabilitation protocols.5 There has also been a movement to address psychosocial factors in postfusion rehabilitative regimens as a means to address nonmedical influencers of patient outcomes. Some European studies have touted the promising results seen when a psychosocial approach is included in the postfusion rehabilitation regimen such as with the Christensen “Back Café” model.6 By supplementing physical measures with multidisciplinary biopsychosocial modalities, patient outcomes are improved across multiple domains.
It is known that lumbar fusion has a detrimental effect on the form and function of the extensor musculature of the lumbar spine.7,8 Relevantly, this deterioration of the paraspinal musculature has been correlated with worse patient-reported outcomes following surgery.9 Physical therapy, specifically focusing on cocontraction of the deep abdominal and multifidus muscles, has been shown to result in paraspinal strength gains in prospective investigation and correlated to lower ODI scores.10,11 For these reasons, we find therapy focusing on a patient’s core and paraspinal musculature a necessary part of optimal patient recovery.
The optimal time to initiate a formal physical therapy regimen in the postoperative period remains undefined beyond the initial mobilization efforts in the acute in-hospital postoperative setting. Oestergaard et al12 found that starting formal rehabilitation exercises at 12 weeks after surgery was more cost-effective and associated with better outcomes compared with starting at 6 weeks following surgery.13 Generally, postfusion physical therapy should continue to at least the 6-month follow-up visit with the surgeon in order to maximize the chances of achieving a successful outcome.3 Of course this duration is variable based on individual patient characteristics such as patient age, comorbidities, and the degree of preoperative deconditioning and disability.
Physical therapy is an integral element of postfusion recovery following both minimally invasive and open lumbar fusion surgery because of its role in alleviating postoperative pain and disability and reducing patient anxiety and fear. In turn, it can serve to increase patient empowerment, gratitude, and satisfaction with the surgery. The fact that up to 40% of patients undergoing lumbar fusion surgery continue to experience debilitating back pain symptoms following surgery points to the necessity for developing a “gold standard” postfusion rehabilitation regimen.14 The current push toward evaluating the efficacy and ideal starting times of the different physical therapy and other rehabilitative modalities through randomized controlled trials will hopefully help elucidate this optimal postfusion rehabilitation regimen in the near future. But for now, because of the improved outcomes demonstrated in the available literature and the very low risk associated with physical treatments, we advocate for routine postoperative physical therapy in patients undergoing lumbar fusion specifically addressing strengthening, cardiovascular exercise, and patient education.
Nicholas Perry, MD, Donald Fredericks, MD, and David Glassman, MD
Lumbar spinal fusion is an increasingly popular procedure intended to address a range of spinal pathologies including unstable spondylolisthesis and spondylosis.15,16 Multiple studies have shown its effectiveness and safety, but the need for formal supervised physical therapy has been debated given the questions of cost and effectiveness. Although several randomized controlled trials have shown physical therapy to be effective in the treatment of nonsurgical back pain, the evidence is sparse with regard to surgically treated lumbar degenerative conditions.3,17,18 Furthermore, recommendations for physical therapy currently used for the lumbar fusion population is primarily extrapolated from microdiscectomy literature and may not apply to the patient population in question. Although we understand the importance of ensuring proper postfusion rehabilitation, we question the medical effectiveness and fiscal responsibility of formal, supervised physical therapy for all patients following spinal fusion and argue that it is not routinely necessary.
We begin our argument against routine postfusion physical therapy by addressing the anatomic changes brought about by lumbar fusion. Proponents of regimented postoperative muscle strengthening protocols often cite surgical muscular disruption and expected postsurgical muscle atrophy as justification for postoperative physical therapy. However, Frodholdt et al19 showed no difference in cross-sectional density, muscle strength, or self-rated extensor or back flexor function in patients at least 7 years from lumbar fusion as compared with a matched nonoperative cohort. Although there may be short-term deficits in strength following surgical intervention, the long-term effects on muscle bulk and function are not significant and the argument that therapy is necessary to maximize long-term outcomes has not borne out in the scientific literature.
What about comparative literature? To our knowledge there are no physical therapy versus no physical therapy group comparisons following lumbar spine surgery, but the usefulness of physical therapy can be scrutinized when compared with other rehabilitation modalities. When compared with more traditional physical therapy regimens, home training exercises combined with group meetings addressing cognitive and behavioral components, have performed better on several patient-reported outcome studies following lumbar spinal fusion procedures.6,20 Abbott et al showed improvements in disability, back pain, fear avoidance behavior in a group of randomized lumbar fusion patients having received additional education and training in cognitive coping strategies, relaxation, and motivational goal setting when compared with a group receiving no formal follow-on care besides the exercise therapy and instructions provided before hospital discharge. Importantly, while these data supports the use of routine therapy, both groups improved compared with baseline in all factors. In addition, while proponents of routine postoperative therapy will tout significant decreases in ODI in the treatment group, this barely met the proposed clinically significant difference of 10, despite increasing the contact time by 1300% with associated increases in cost of care. The bottom line is that while there is some evidence out there to suggest a benefit to therapy, it is not very clear-cut. This is underscored by a recent meta-analysis that was unable to find high-quality objective data that demonstrated efficacy of routine formal physical therapy after spinal fusion procedure.21
When assessing the value of physical therapy, it is also important to consider the influence of the psychosocial training and its influence on patient outcomes as these interventions are often involved in formal physical therapy regimens. Archer et al22 showed decreased pain and disability and increased general health when cognitive and behavioral modalities were added to usual physical therapy treatment protocols. Christensen and Soegaard’s Back Café model of group meetings in postsurgical lumbar fusion patients, when compared with exercise therapy alone, showed reduction in primary health service utilization and cost while at the same time showing a rise in patient-reported outcomes.6,23 In the setting of matched physical therapy regimens following fusion surgery Rolving et al24 showed increased mobility, less rescue analgesics in the acute postoperative group having undergone preoperative cognitive behavioral therapy as compared with control group. Although these studies may appear to show a benefit to formalized therapy, careful analysis of the methods raises the question of what element of therapy is beneficial to postoperative patients. On the basis of our interpretation of these studies, we feel that it is the psychosocial interventions, not the physical ones, which account for the largest impact on patient outcomes, and these interventions could likely be performed in a much more cost-conscious and resource-efficient manner.
On the basis of our review of current literature, we do not feel that all patients need formal, supervised physical therapy as part of their postoperative protocol. The purpose of this argument is not to dissuade clinicians from using physical therapy as a tool to provide benefit to their patients, but rather to provide insight into what modalities might be most useful and what interventions should supplement their prescribed rehabilitation. Although there is some data to support continued rehabilitation following lumbar fusion, there is less data to convincingly support formal physical therapy training beyond prescribed home exercises and early weight bearing. With taxing appointment schedules and the additional costs associated with formal physical therapy appointments, patients may benefit more from physician education and exercise encouragement in combination with periodic cognitive behavioral interventions. So, rather than a one size fits all approach to postoperative physical therapy, we recommend reserving supervised physical therapy for more complex or concerning patients, as this approach will provide the maximum patient outcomes benefit while minimizing the overall cost to the health care system.
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19. Froholdt A, Holm I, Keller A, et al. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Spine J. 2011;11:718–725.
20. Sogaard R, Bünger CE, Laurberg I, et al. Cost-effectiveness evaluation of an RCT in rehabilitation after lumbar spinal fusion: a low-cost, behavioural approach is cost-effective over individual exercise therapy. Eur Spine J. 2008;17:262–271.
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