Lumbar diskectomy is a highly effective treatment for radiculopathy patients who meet the indications for surgery. Many surgeons include post-operative physical therapy (PT) as part of their protocol, though there is little high quality data to support this. Anecdotally, most lumbar diskectomy patients seem to do quite well without any PT, though a minority have a difficult time returning to work and their regular activities. In order to better assess the effectiveness of post-diskectomy PT, Dr. Paulsen and colleagues from Denmark performed a Level 1 RCT in which lumbar diskectomy patients were randomized to outpatient PT starting 4-6 weeks post-operatively or to no PT. Both groups received instructions about home exercises prior to discharge from the hospital and were instructed to advance their activities as tolerated without restrictions. Seventy-three patients were randomized to each group, and there were no significant baseline differences between the groups. They were followed out to 2 years, and both groups improved significantly on all patient reported outcomes (PROs). There were no significant differences between the two groups on the ODI, EQ-5D, or VAS leg pain or VAS back pain scores out to 2 years. These outcomes were measured at 1, 3, 6, 12, and 24 months after surgery. Ten patients in the PT group and 9 patients in the no PT group underwent reoperation within one year (13% overall), with the vast majority of these being revision diskectomies for recurrent disk herniation. Other complication rates were very low and similar between the two groups. The authors concluded that post-diskectomy PT did not improve PROs.
The authors have performed a simple but high quality study that demonstrated convincingly that post-diskectomy outpatient PT starting 4-6 weeks after surgery did not improve PROs. There was a small amount of crossover between the groups, but the as-treated and per protocol analyses showed the same result. One of the limitations of this study was that PT did not start until 4-6 weeks after surgery, and many patients had likely already returned to completely normal function at this point. One month after surgery was the earliest time at which PROs were recorded, and much of the improvement had occurred prior to this. The authors also did not evaluate when patients returned to work and activities, and these outcomes may have been affected by PT. The revision surgery rate was relatively high in the first year (13% compared to 6% in SPORT), though it was nearly identical for the two groups. The authors' conclusion that outpatient PT starting 4-6 weeks after diskectomy did not affect PROs measured from 1-24 months post-operatively appears completely valid. However, it is possible that starting PT earlier may have hastened return to work and activities. Given that the surgeons did not use activity restrictions, it is unclear why PT did not start earlier. Additionally, PT was provided to all patients randomized to it, and clearly not all patients benefit from it. However, there may be a subgroup of patients at risk for a slower recovery (i.e. those with fear avoidance behavior, worker's compensation claims, heavy work demands, etc.) who would benefit from early PT. This paper suggests that routinely referring all diskectomy patients to PT one month after surgery is probably not helpful. There are likely patients who do benefit from early PT, though who these patients are and how early to start PT remain to be determined.
Please read Dr. Paulsen's article on this topic in the January 1 issue. Does this change how you view the role of post-diskectomy PT? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor