A Person-Centered Prehabilitation Program Based on Cognitive-Behavioral Physical Therapy for Patients Scheduled for Lumbar Fusion Surgery: A Randomized Controlled Trial

Abstract

Background Prehabilitation programs have led to improved postoperative outcomes in several surgical contexts, but there are presently no guidelines for the prehabilitation phase before lumbar fusion surgery. Objective The objective was to investigate whether a person-centered physical therapy prehabilitation program, based on a cognitive-behavioral approach, is more effective than conventional care in reducing disability and improving functioning after lumbar fusion surgery in patients with degenerative disk disease. Design This study was a randomized controlled trial. Setting The study took place at 2 private spine clinics and 1 university hospital. Patients We prospectively enrolled 118 patients scheduled for lumbar fusion surgery. Intervention The active intervention used a person-centered perspective and focused on promoting physical activity and targeting psychological risk factors before surgery. The control group received conventional preoperative care. Measurements The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on 6 occasions up to 6 months postoperatively. A linear mixed model was used to analyze the change scores of each outcome. Results No statistically significant between-group difference was found on the primary outcome (disability) over time (baseline to 6 months). Among secondary outcome measures, a statistically significant interaction effect (“Group × Time”) was seen for the European Quality of Life 5 Dimensions Questionnaire. The largest between-group difference on the European Quality of Life 5 Dimensions Questionnaire index was seen 1 week prior to surgery and favored the active intervention. The largest between-group effect sizes at the 6-month follow-up favored the active intervention, and were seen for physical activity intensity, steps per day, and the One Leg Stand Test. Both groups reached the minimal important change for the primary outcome and, in several secondary outcomes (pain intensity, back and leg; pain catastrophizing; anxiety; health-related quality of life [EQ5D VAS]), already at 8-week follow-up. Limitations The participants’ preoperative level of disability was lower than normative values, which suggests selection bias. Conclusions Both interventions led to clinically important changes, but it is not clear what kind of prehabilitation program is the most effective.

Implementing a behavioral medicine approach in physiotherapy for patients with musculoskeletal pain: a scoping review

“…Studies that contributed to the results were from Australia, 51 Ireland, 40 Norway, 9 , 10 , 56 , 57 Sweden, 4 , 6 , 8 , 19 , 23 , 28 , 34 , 35 , 42 , 43 , 45 , 49 the United Kingdom, 27 , 58 and the United States. 3 , 44 …”

“…One study was targeted at adolescents, 28 3 were targeted at older persons, 8 – 10 , 44 and the rest of the studies were targeted at people of working age. 3 , 4 , 6 , 19 , 23 , 27 , 34 , 35 , 40 , 42 , 43 , 45 , 49 , 51 , 56 – 58 …”

Psychologically informed physical therapy for musculoskeletal pain: current approaches, implications, and future directions from recent randomized trials

“…We intended a broad condition focus that would include both nonoperative and postoperative patients, but did not find any postoperative studies that directly compared PIPT to standard physical therapy. A few notable postoperative PIPT studies that did not meet this specific criterion, but should be considered when determining the value of postoperative PIPT, include studies by Archer et al, 2 Lotzke et al, 47 Riddle et al, 73 Peolsson et al, 68 and Wibault et al 88 Most of these postoperative studies compared a PIPT approach to usual postoperative care, which may have included physical therapy.…”

Rehabilitation in adult spinal deformity

“…However, total spinal range of motion is usually not limited, since fusion usually involves few segments,[ 41 ] not greater than three levels. [ 42 , 43 ] Bone grafts are used to stimulate bone fusion between the target vertebrae, which takes several months. During healing time, the fused spine must be kept in proper alignment.…”

“…Counseling and education for postoperative physical activity, including early inpatient mobilization and core exercises, and time to return to activities of daily living, sports, or work should be provided. [ 43 , 51 ]…”