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Workshop 3 Discectomy, Laminectomy and Fusion: Therapy and Post-surgery Recovery

Workshop 3 Discectomy, Laminectomy and Fusion: Therapy and Post-surgery Recovery. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE Maureen Dwight, Registered Physiotherapist, Clinical Musculoskeletal Specialist, ISAEC Practitioner Co-founder Spine Therapy Network

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Workshop 3 Discectomy, Laminectomy and Fusion: Therapy and Post-surgery Recovery

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  1. Workshop 3 • Discectomy, Laminectomy and Fusion: Therapy and Post-surgery Recovery

  2. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE • Maureen Dwight, Registered Physiotherapist, Clinical Musculoskeletal Specialist, ISAEC Practitioner • Co-founder Spine Therapy Network • Director The Orthopaedic Therapy Clinic

  3. The Facts: Spinal surgery rates are increasing worldwide This Photo by Unknown Author is licensed under CC BY-SA

  4. Most frequent surgeries are for: • Spinal stenosis • Disc herniation This Photo by Unknown Author is licensed under CC BY-SA

  5. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE • Many of us are involved with these patients pre-op • - but should we be? • Many of us never see these patients post-operatively • - but should we? • Many of us never receive referrals directly from the surgeon’s post-op. • - why not? • I

  6. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE • The controversies • No literature to support therapy • Post-operative rehab is not needed – wastes resources.

  7. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE • Education is as effective as therapeutic exercise programs. • Should we be providing full behavioural rehab programs or single discipline exercise programs? • Post-operative rehab increases the risk for further surgery.

  8. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE • Spinal Stenosis

  9. The Facts: Spinal stenosis surgery increasing due to aging population This Photo by Unknown Author is licensed under CC BY-SA

  10. 66 y.o. female with spinal stenosis. Should she have therapy or surgery? What would you tell her? This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-SA

  11. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE STENOSIS Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review Alison H. McGregor , PhD , et al Spine vol 39 #13 pp 1044-1059, 2014

  12. The Facts • Conservative care for spinal stenosis: Little support in the literature • We need better quality studies

  13. The Facts • Surgery for spinal stenosis has better short term outcomes than conservative care • The difference lessens over the long term > 1 yr* *American pain society CPC 2009 This Photo by Unknown Author is licensed under CC BY-NC-SA

  14. 66 y.o. female with spinal stenosis • What would you tell her? • It’s her choice. • Surgery will have a better short term result but over the long term there is little difference. This Photo by Unknown Author is licensed under CC BY-SA

  15. Cochrane review - Rehab after spinal stenosis surgery • Is there a role for therapy after surgery to improve outcomes? • What is the gap?

  16. Cochrane 2014 Spinal Stenosis surgery systematic review Post-surgical outcomes Moderate improvement in function • 58-69% Low Satisfaction rates • 15-81% This Photo by Unknown Author is licensed under CC BY-SA

  17. Cochrane 2014 Spinal Stenosis surgery systematic review • Evidence of trunk muscle dysfunction • Muscles are known to be damaged by surgery This Photo by Unknown Author is licensed under CC BY-SA

  18. Cochrane 2014 Spinal Stenosis surgery systematic review Pre-review statement: These findings would suggest that Rehab would be promising post-op in improving outcomes This Photo by Unknown Author is licensed under CC BY

  19. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review Review question: Whether active rehab programs after spinal stenosis have an impact on functional outcomes and whether these programs are better than “usual care”?

  20. Same 66 y.o. old Now post-op for spinal stenosis with residual back and leg pain. Wants to garden this spring.

  21. Can you help her to: • Reduce her low back pain? • Reduce her leg pain? • Improve her function?

  22. When should she start therapy? • Should she be afraid of hurting her surgery results with exercise?

  23. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review 1726 articles to review 3 included

  24. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review Definition of “usual care”: • Post-operatively provided limited advice to stay active • Brief general program of exercise directed at preventing DVT

  25. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review Recommendations Moderate evidence supporting rehab post spinal stenosis surgery

  26. Cochrane review - Rehab after lumbar stenosis surgery Can you help her to: Reduce her low back pain? Yes Active rehab is better than usual care in the short term for reducing post-operative low back pain

  27. Cochrane review - Rehab after lumbar stenosis surgery Can you help her to: Reduce her leg pain? Yes - Active rehab is better than usual care in the short and long term for reducing post-operative low back pain and leg pain

  28. Cochrane review - Rehab after lumbar stenosis surgery Can you help her to: Improve her function? Yes - now & for the future Active rehab is better than usual care in both short term and long term functional status post-spinal stenosis surgery

  29. Cochrane review - Rehab after lumbar stenosis surgery When should she start therapy? Active rehab within 6 mos. post-op is more effective than usual care to improve: • Function • LBP • No difference in leg pain

  30. Cochrane review - Rehab after lumbar stenosis surgery When should she start therapy? Active rehab started within 12 mos. post-op is more effective than usual care to improve: • function • lbp • leg pain

  31. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review Should she be afraid of hurting her surgery results with exercise? No There was no increased risk of re-operative rates in these studies.

  32. Disc Herniations

  33. 29 y.o. male athlete Acute L5 root with L5-S1 disc herniation confirmed on MRI. 3/12 post-onset This Photo by Unknown Author is licensed under CC BY-SA

  34. Should he have therapy or surgery? This Photo by Unknown Author is licensed under CC BY-SA

  35. Natural history of disc herniation recovery 38% - clinically improved 1/12 53% - clinically improved 2/12 73% - clinically improved 3/12

  36. The Facts • Conservative care for disc herniation: Little support in the literature • We need better quality studies

  37. The Facts • Surgery has better short term outcomes than conservative care • The difference lessens over the long term > 1 yr.

  38. 29 y.o. male athlete What do you tell him? • It’s his choice. • Surgery will have a better short term result but over the long term there is little difference.

  39. Same 29 y.o. male athlete now post-op Microdiscectomy & Laminotomy Continues to have back and leg pain

  40. When should he start to exercise? What intensity of program is best? Should he worry about damaging the surgery?

  41. Should you develop post-op education handouts? Should he see a CBT therapist and/or a rehab program counsellor for a comprehensive program?

  42. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE LUMBAR DISC SURGERY • Cochrane review 2014 • Rehab after lumbar disc surgery • T Oosterhuis et al • Updated 2002

  43. Cochrane review - Rehab after lumbar disc surgery • Surgeries included: • Discectomy • Microdiscectomy • Laminectomy with microdiscectomy • 8 new studies met the criteria, 22 in total

  44. Cochrane review - Rehab after lumbar disc surgery • Included studies where post-operative care began: • Immediately post-op • 4-6 months post-op • 1 year or longer post-op • .

  45. Cochrane review - Rehab after lumbar disc surgery • Looked at exercise programs vs. Rehab programs • Rehab programs definition: • Multidisciplinary programs • Stretch and strength exercises • Behavioral graded activity

  46. Cochrane review - Rehab after lumbar disc surgery • In these studies: • The exercise interventions provided were uncontrolled • And highly variable

  47. Cochrane review - Rehab after lumbar disc surgery Conclusions: • No high or moderate-quality evidence identified. • Further high quality randomized controlled studies needed This Photo by Unknown Author is licensed under CC BY-SA

  48. Cochrane review conclusions - Rehab after lumbar disc surgery • These programs lead to a faster decrease in pain & better function than no treatment (low quality) • High-intensity exercise programs lead to slightly faster decrease in pain & disability than low-intensity programs (very low quality) • Home exercise programs for pain relief, disability or global perceived effect were as effective as supervised exercise programs (very low quality)

  49. Cochrane review - Rehab after lumbar disc surgery • Education on it’s own did not have as strong an outcome as physiotherapy exercise programs (low quality) • There is less support for including a full rehab program than providing an exercise only program in the immediate post-op period (low quality)

  50. 29 y.o. male athlete When should he start exercise? Exercise programs started at 4-6 months post-op are better than no Rx

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