A prospective, randomised trial of immediate exercise following lumbar microdiscectomy: a preliminary study.
Article Type: Report
Subject: Discectomy (Usage)
Discectomy (Standards)
Discectomy (Patient outcomes)
Intervertebral disk displacement (Care and treatment)
Intervertebral disk displacement (Patient outcomes)
Exercise (Health aspects)
Intervertebral disk (Hernia)
Intervertebral disk (Care and treatment)
Intervertebral disk (Patient outcomes)
Author: Watson, Jody
Pub Date: 07/01/2010
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2010 Source Volume: 38 Source Issue: 2
Topic: Event Code: 350 Product standards, safety, & recalls
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 263992604
Full Text: Newsome RJ, May S, Chiverton N and Cole AA (2009): A prospective, randomised trial of immediate exercise following lumbar microdiscectomy: a preliminary study, Physiotherapy 95: 273-279.

Background: Patients with disc herniation do not usually respond to non-operative therapy. Microdisecetomy is generally regarded as the gold standard for surgery and has been shown to result in shorter operative times, quicker return to work and similar long term outcomes compared to more aggressive forms of surgery. Currently, multiple post-operative regimes are used in hospital settings, most of which contain exercise programmes, but few commence immediately post-surgery. With increasing cost pressures on health care systems it is important that regimes are as effective as possible with the aim of reducing length of stay.

Aim: To assess whether commencing exercises immediately following lumbar microdiscectomy enabled patients to become independently mobile earlier with no increased risk of complications.

Methods: Thirty patients were recruited who met the inclusion criteria of first- time single level lumbar microdiscectomy; failure to respond to conservative treatment; and magnetic resonance imaging revealed a disc prolapsed at a level consistent with symptoms. Exclusion criteria were: previous discectomy; more than one level indicated; and emergency cauda equina surgery. Participants were randomly allocated to either the intervention (n=15, 46% male, median age 38) or control (n=15, 73% male, median age 37) group. Those in the intervention group commenced exercises within 2 hours of surgery beginning with bed exercises, progressing to mobilising out of bed within 5 hours, and becoming independent as they felt able. The control group did not receive bed exercises but did mobilise within 4-5 hours of surgery. Both groups were given the same standard exercise and advice sheets. Outcome measures included the time taken to become independently mobile, time to fulfill discharge criteria and return to work, along with the Oswestry Disability Scale, Visual Analogue Scale and the Short Form McGill Pain Questionnaire. Measures were taken before surgery, and 4 weeks and 3 months post-surgery.

Results: The intervention group became independently mobile earlier than the control group (median 7 hours, compared with 19 hours for control group) and if employed, returned to work more rapidly (median 6 weeks, compared with 8 weeks for control group). At 15 hours post-surgery 80% of the intervention group were independently mobile compared with only 40% of the control group. Pain and disability scores were similar in both groups with improvement after surgery. One revision occurred in each group which is consistent with reported revision rates.

Conclusion: The authors suggest patients undergoing microdiscectomy should begin bed exercises within 2 hours of surgery and become independently mobile the same day. This may lead to improved health outcomes, decreased length of hospital stay and reduced costs to health care.

Commentary

It has been suggested that microdiscectomy is the gold standard for surgical treatment of lumbar disc herniation (Apostolides et al 1996), a problem that likely represents no more than 5% of the back pain population (Adams et al 2006). Anecdotal evidence suggests that most surgeons in New Zealand tend to only provide restrictive advice following microdiscectomy, i.e., outlining movements that patients are not allowed to perform, for example, flexion (www.healthpoint.co.nz; www.orthopaedicsurgeon.co.nz). They may also prescribe progressive walking programmes aiming for independence as soon as possible post-operatively, followed by a gradual increase in activity as tolerated, returning to work as soon as possible. Some surgeons will recommend outpatient physiotherapy, if required, a few weeks post-operatively.

This preliminary study highlights the input that physiotherapists can provide in the immediate post-operative phase following microdiscectomy. The authors accept that the sample size is small, although in the discussion they state they have used the immediate exercise regime in over 2000 patients since the trial, with promising results. The exercises used in this study are simple to teach to patients and straightforward for patients to perform. They involved the physiotherapist passively flexing the patient's hip and knee towards his/her chest within the available range and tolerance. This movement was repeated 10 times on one lower limb and then the other. The patient was then encouraged to perform these exercises every 30 minutes.

Although those in the intervention group became independently mobile, and returned to work earlier than those in the control group, no significant differences in traditional questionnaire-based outcome measures were reported, or any difference at the 3 month follow-up. While this study provides evidence for short-term benefits, no comment can be made on long-term outcome. The authors discuss the possibilities of further research and suggest that earlier outpatient physiotherapy may be required. Given the skills that physiotherapists have in pain management, exercise prescription and rehabilitation, further research into continuing care post-microdiscectomy would be beneficial.

Jody Watson, BPhty

PhysioMed

Dunedin

REFERENCES

Adams M, Bogduk N, Burton K, Dolan P (2006): The Biomechanics of Back Pain (2nd ed.). Edinburgh: Churchill Livingstone, pp. 59.

Apostolides PJ, Jacobwitz R, Sonntag VKH (1996): Lumbar discectomy microdiscectomy: the gold standard. Clinical Neurosurgery 43: 228-238.

www.healthpoint.co.nz [Accessed 5 July, 2010]

www.orthopaedicsurgeon.co.nz [Accessed 5 July, 2010]
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.