Objective To assess the effectiveness of prehabilitation in patients with degenerative disorders of the lumbar spine who are scheduled for spine surgery. Design Intervention systematic review with meta-analysis. Literature Search Seven electronic databases were systematically searched for randomized controlled trials or propensity-matched cohorts. Study Selection Criteria Studies that measured the effect of prehabilitation interventions (ie, exercise therapy and cognitive behavioral therapy [CBT]) on physical functioning, pain, complications, adverse events related to prehabilitation, health-related quality of life, psychological outcomes, length of hospital stay, use of analgesics, and return to work were included. Data Synthesis Data were extracted at baseline (preoperatively) and at short-term (6 weeks or less), medium-term (greater than 6 weeks and up to 6 months), and long-term (greater than 6 months) follow-ups. Pooled effects were analyzed as mean differences and 95% confidence intervals (CIs). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Results Cognitive behavioral therapy interventions were no more effective than usual care for all outcomes. Pooled effect sizes were −2.0 (95% CI: −4.4, 0.4) for physical functioning, −1.9 (95% CI: −5.2, 1.4) for back pain, and −0.4 (95% CI: −4.1, 0.4) for leg pain. Certainty of evidence for CBT ranged from very low to low. Only 1 study focused on exercise therapy and found a positive effect on short-term outcomes. Conclusion There was very low–certainty to low-certainty evidence of no additional effect of CBT interventions on outcomes in patients scheduled for lumbar surgery. Existing evidence was too limited to draw conclusions about the effects of exercise therapy. J Orthop Sports Phys Ther 2021;51(3):103–114. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9748
Purpose On average, 56% of patients report a clinically relevant reduction in pain after lumbar spinal fusion (LSF). Preoperatively identifying which patient will benefit from LSF is paramount to improve clinical decision making, expectation management and treatment selection. Therefore, this multicentre study aimed to develop and validate a clinical prediction tool for a clinically relevant reduction in pain 1 to 2 years after elective LSF. Methods The outcomes were defined as a clinically relevant reduction in predominant (worst reported pain in back or legs) pain 1 to 2 years after LSF. Patient-reported outcome measures and patient characteristics from 202 patients were used to develop a prediction model by logistic regression. Data from 251 patients were used to validate the model. Results Nonsmokers (odds ratio = 0.41 [95% confidence interval = 0.19–0.87]), with lower Body Mass Index (0.93 [0.85–1.01]), shorter pain duration (0.49 [0.20–1.19]), lower American Society of Anaesthesiologists score (4.82 [1.35–17.25]), higher Visual Analogue Scale score for predominant pain (1.05 [1.02–1.08]), lower Oswestry Disability Index (0.96 [0.93–1.00]) and higher RAND-36 mental component score (1.03 [0.10–1.06]) preoperatively had a higher chance of a clinically relevant reduction in predominant pain. The area under the curve of the externally validated model yielded 0.68. A nomogram was developed to aid clinical decision making. Conclusions Using the developed nomogram surgeons can estimate the probability of achieving a clinically relevant pain reduction 1 to 2 years after LSF and consequently inform patients on expected outcomes when considering treatment.
To explore the association between preoperative physical performance with short-and long-term postoperative outcomes in patients undergoing lumbar spinal fusion (LSF). Design: Retrospective cohort. Setting: University hospital. Participants: Seventy-seven patients (N=77) undergoing elective LSF were preoperatively screened on patient demographics, patient-reported outcome measures, and physical performance measures (movement control, back muscle endurance strength and extensor strength, aerobic capacity, flexibility). Interventions: Not applicable. Main Outcome Measures: Associations between preoperative variables and inpatient functional recovery, hospital length of stay (LOS), and 1-to 2-year postoperative pain reduction were explored using random forest analyses assessing the relative influence of the variable on the outcome. Results: Aerobic capacity was associated with fast functional recovery <4 days and prolonged functional recovery >5 days (median z scores=7.1 and 12.0). Flexibility (median z score=4.3) and back muscle endurance strength (median z score=7.8) were associated with fast functional recovery <4 days. Maximum back extensor strength was associated with prolonged functional recovery >5 days (median z score=8.6). Flexibility (median z score=5.1) and back muscle endurance strength (median z score=13.5) were associated with short LOS <5 days. Aerobic capacity (median z score=8.7) was associated with prolonged LOS >7 days. Maximum back extensor strength (median z score=3.8) was associated with 1-to 2-year postoperative pain reduction and aerobic capacity (median z score=2.8) was tentative. Conclusions: Physical performance measures were associated with both short-and long-term outcomes after LSF. Adding these measures to prediction models predicting outcomes after LSF may increase their accuracy.
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