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Key messages and advice about rehabilitation from lumbar surgery

At a glance:
When it comes to patient management after spinal surgery, advice can vary. This leaves surgeons and patients unsure about restrictions, becoming active again and returning to work. This study reviewed the research and developed evidence-based recommendations for patients who have had lumbar
lumbar
relating to the part of the back between the ribs and the hipbones
 discectomy or spinal decompression.
decompression
Surgical procedure that is performed to alleviate pain caused by pinched nerves. A small portion of the bone over the nerve root and/or disc
disc
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae.  Disks
disk
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disc.
  have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disk.
 material from under the nerve root is removed to give the nerve root more space and help it heal.
 The recommendations included:

Remain mobile and return to full activities as soon as possible after surgery. This produces better relief of pain, and an earlier return to work
Early post-operative rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 programs help with daily activities
Early post-operative rehabilitation programs improve return-to-work rates/time
Returning to work as quickly as possible is generally beneficial. It results in faster recovery and better clinical outcomes. Some studies suggest that returning to work may be possible after as little as one week, but this will depend on the nature of the work and the surgical procedure.
Workers should aim for a gradual return to their previous duties at work
Work and exercise are good for physical and mental health
Patients' expectations and satisfaction are important factors—knowing what to expect helps recovery.
The concept of ‘let pain be your guide' is counterproductive. Patients should try to remain active despite the pain as this will speed recovery.
Perspectives:
Employee
Lumbar surgery is common for disc prolapse
disc prolapse
When a disc has extended out from its normal position. A disc prolapse can be normal (30-80% people without back pain have some degree of disc bulge
disc bulge
When a disc has extended out from its normal position. A disc bulge can be normal (30-80% people without back pain have some degree of disc bulge on a back scan). In other cases the disc can press on the nerve and cause sciatica
sciatica
Pain caused by pressure on a branch of the sciatic nerve, which starts in the lower back and runs through the legs. The pain is felt in the leg and foot. There may also be numbness, weakness or difficulty moving the leg.
 or leg pain. Also called a disc prolapse or disc herniation.
 on a back scan). In other cases the disc can press on the nerve and cause sciatica or leg pain. Also called a disc herniation or disc bulge.
 and spinal stenosis. Patients' recovery after the operation can vary, and some patients continue to have problems. Good advice about what to do after surgery is important for your rehabilitation.

Discuss rehabilitation after surgery with your specialist. Use the recommendations established in this study as a discussion primer. It is best to do this before your surgery so you can plan your recovery in advance. It may be worthwhile having a special appointment with your specialist to discuss this, if there is not enough time in the other consultations.
Employer
This study reviewed evidence on whether patients should restrict their activities after having lumbar surgery. There is little evidence that patients should avoid activity, and keeping active may actually help people to recover.

If you have an employee who is cautious about returning to work after lumbar surgery, offer them modified duties or hours so they feel comfortable returning to some level of activity at work.

Encourage the employee to discuss these issues with their specialist. Encourage them to get clear advice from their doctor, as they may need to be assured that activity will not cause them to re-injure their back.
Treater
This article reviewed the evidence about how best to manage rehabilitation after a lumbar discectomy or spinal decompression, with a view to develop an information booklet for patients. The systematic review
systematic review
A comprehensive review of research studies in a particular area. The review follows guidelines to ensure the studies included are valid.
 revealed little evidence for post-operative restrictions.

The authors of this review noted that ill-founded advice to restrict activity after surgery may delay recovery. If people do not return to activity they are at greater risk of long term disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 while returning to productive work increases the likelihood of successful return to work. Enabling advice is important.

The authors comment that many restrictions are put in place because of convention. Treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
  can have a tendency to be cautious to protect the patient. However in the management of back pain being cautious can have significant negative consequences for the patient.
Insurer
This article reviewed the evidence about how to best manage rehabilitation after a lumbar discectomy or spinal decompression. The systematic review revealed that there is little evidence for any post-operative restrictions.

A lack of advice about returning to activity can make patients uncertain what they should and shouldn't do, which is likely to increase their anxiety and interfere with their rehabilitation. Encourage patients undergoing surgery to get clear advice about their rehabilitation.
Original Article, Authors & Publication Details:
A. McGregor1, A. Burton2, P. Sell3 and G. Waddell4 (2007).

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression
. European Spine Journal; 16(3):339-346

1Biosurgery and Surgical Technology, Faculty of Medicine, Imperial College London, Charing Cross Hospital Campus, London W6 8RF, UK
2Spinal Research Unit, University of Huddersfield, Huddersfield, UK
3University of Leicester Hospitals NHS Trust and Queen's Medical Centre Nottingham NHS Trust, Nottingham, UK
4Unumprovident Centre for Psychosocial and Disability Research, University of Cardiff, Cardiff, UK
Background, Study Objectives, How It Was Done:
Lumbar surgery for disc prolapse and spinal stenosis
spinal stenosis
A medical condition in which the spinal canal
spinal canal
Space in vertebrae
vertebrae
(singular: vertebra) The individual irregular bones that make up the spinal column.
 through which the spinal cord passes
 (space in vertebrae through which the spinal cord passes) narrows and compresses the spinal cord and nerves.
 is common. Patients' recovery after the operation can vary. Many patients continue to have recurrent back pain, or nerve root pain and some develop disability. Overall, approximately 20% of patients will become long-term disabled. Residual symptoms and psychosocial
psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 factors increase the risk of disability.

Good surgical outcomes depend on:

(a) The technical outcome of surgery and
(b) Post-operative recovery and rehabilitation.

Successful surgery does not guarantee complete recovery. Good post-operative management is important for a patient's rehabilitation.

Previous research shows that post-operative exercise improves a patient's function, and that activity after surgery is not harmful. A recent study suggests that return to work is delayed by restricting activity. Yet a recent UK survey showed that surgeon's advice varied when it came to restricting activities after the operation, and many patients in the UK receive little formal rehabilitation. Lack of advice, or inconsistent and contradictory advice, makes patients uncertain what they should and shouldn't do. This is likely to increase their anxiety and interfere with their rehabilitation.

Most patients want accurate, practical information and advice, but the information available to them varies in quality and could increase confusion. This project's first aim was to review the scientific evidence on post-operative management after a lumbar surgery, and to summarise this information into key messages and advice. Its second aim was to incorporate these messages into an information booklet for patients and surgeons, specifically for lumbar disc
lumbar disc
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Also called an invertebral disc.
 prolapse and spinal stenosis surgery.

A systematic search of the scientific research was completed. Studies published between 1984 and 2005 were included.

Messages for the patient booklet were adapted from the evidence statements from the review of the scientific literature. The aim of the booklet was to improve understanding, reduce uncertainty and anxiety, promote positive expectations and build confidence during recovery.

To foster realistic expectations and to reduce anxiety the possibility of residual back pain and other problems was discussed frankly and openly.

The booklet was reviewed by health professionals and by patients.
Study Findings:
119 papers were considered, and 32 provided useful evidence.

The studies agreed that patients do not know what they should do during recovery from surgery; they need better information that is consistent and evidence-based.

After an extensive review of the research, the authors listed a series of facts and recommendations relating to two topics:

A. Restrictions following spinal surgery
B. Return to activity and work and rehabilitation

Restrictions following spinal surgery:

There is no empirical evidence supporting post-operative restrictions on activity.
There is strong evidence that most post-operative restrictions are not necessary.
There is strong evidence that most post-operative restrictions delay recovery and return to work.
Limited evidence suggests that restricting specific activities (e.g. lifting, pushing or pulling) may also be unnecessary.
Many patients are uncertain about what activities they can or should undertake after back surgery.
Surgeon's beliefs when it comes to restricting activity.
Putting restrictions on activity after surgery seems to be influenced by the anxiety and uncertainty of patients and clinicians.
 
Return to activity and work:

Encouraging mobility and returning to full activities as soon as possible after surgery results in better pain-relief and an earlier return to work.
There is strong evidence that early post-operative rehabilitation programs improve daily living activities.
There is strong evidence that early post-operative rehabilitation programs improve the chances of returning to work, and reduce the amount of time it takes to return to work. Focusing on information about disability and activity has been shown to be an effective approach within these programs.
There is strong evidence that returning to work as quickly as possible is beneficial. Some studies suggest patients can return as early as 1 week after surgery, but this will depend on the nature of the work and the surgical procedure. This results in a faster recovery and better clinical outcomes.
Patients should aim for a gradual return to previous duties at work.
Work and exercise are good for physical and mental health.
Recovery is fastest during the first 3 months after surgery. After that, improvements take more time. This is the case for clinical outcomes like pain and function as well as vocational
vocational
Related to work or career. Vocational rehabilitation focuses on the process of returning to the workforce.
 outcomes like successfully returning to work.
There is moderate evidence that patients' expectations and satisfaction are important factors. Knowing what to expect aids recovery.
The concept of ‘let pain be your guide' to guide reactivation is unhelpful and slows down recovery. Patients should be encouraged to be as active as possible despite the discomfort.
 
Currently, doctors' advice and practice do not always follow the scientific evidence. Some surgeons tell patients to restrict their activity after surgery; on other occasions exercise and rehabilitation are recommended. Health professionals may be unaware of the evidence, and rather rely on their training or personal experience, but advice that is not scientifically-based may delay recovery.
Conclusions:
Patients want and deserve the best possible information and advice. Currently, patients who undergo lumbar surgery are given inconsistent advice. Informing patients can reduce anxiety, promote psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 wellbeing and improve compliance.

The scientific evidence supports an early return to work and activity after lumbar surgery.
References:
PubMed Abstract
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