Patient and physiotherapist perceptions of rehabilitation following primary lumbar discectomy: a qualitative focus group study embedded within an external pilot and feasibility trial.

OBJECTIVE: To evaluate patients' and physiotherapists' perceptions, preferences and feelings about rehabilitation following lumbar discectomy surgery. DESIGN: A qualitative focus group study, informed from the theoretical perspective of phenomenology, of patients' and physiotherapists' experiences of rehabilitation following lumbar discectomy was conducted. The focus groups were used to explore patients' and physiotherapists' perceptions and their preferences and feelings about different approaches to rehabilitation. The focus groups were facilitated and observed by experienced researchers and were informed by a topic guide that had been piloted previously. SETTING: The study was embedded within an external pilot and feasibility trial that randomised patients across two secondary care spinal surgery sites in the UK to receive either 1:1 physiotherapy and leaflet or leaflet-only interventions. PARTICIPANTS: Five focus groups took place between April and July 2014. A framework analysis of thematic coding (deductive and inductive components) by two researchers captured identified themes common to both patients and physiotherapists. Data from three focus groups with patients and carers (n=11) and two with physiotherapists (n=15) contributed to the analytic framework. RESULTS: Emerging themes included: the value of patient leaflets with or without physiotherapy interventions; the importance of self-motivation in the recovery pathway; benefits of group physiotherapy for some patient groups and patient preference influencing rehabilitation. CONCLUSION: Patients and physiotherapists perceived the study patient leaflet and 1:1 physiotherapy interventions as high quality and valuable. Patients' personal priorities, for example, their need to return to work, influenced their preferences for rehabilitation interventions following surgery.

Physiotherapy Post Lumbar Discectomy: Prospective Feasibility and Pilot Randomised Controlled Trial.

OBJECTIVES: To evaluate: acceptability and feasibility of trial procedures; distribution of scores on the Roland Morris Disability Questionnaire (RMDQ, planned primary outcome); and efficient working of trial components. DESIGN AND SETTING: A feasibility and external pilot randomised controlled trial (ISRCTN33808269, assigned 10/12/2012) was conducted across 2 UK secondary care outpatient physiotherapy departments associated with regional spinal surgery centres. PARTICIPANTS: Consecutive consenting patients aged >18 years; post primary, single level, lumbar discectomy. INTERVENTIONS: Participants were randomised to either 1:1 physiotherapy outpatient management including patient leaflet, or patient leaflet alone. MAIN OUTCOME MEASURES: Blinded assessments were made at 4 weeks post surgery (baseline) and 12 weeks post baseline (proposed primary end point). Secondary outcomes included: Global Perceived Effect, back/leg pain, straight leg raise, return to work/function, quality of life, fear avoidance, range of movement, medication, re-operation. RESULTS: At discharge, 110 (44%) eligible patients gave consent to be contacted. 59 (54%) patients were recruited. Loss to follow up was 39% at 12 weeks, with one site contributing 83% losses. Mean (SD) RMDQ was 10.07 (5.58) leaflet and 10.52 (5.94) physiotherapy/leaflet at baseline; and 5.37 (4.91) leaflet and 5.53 (4.49) physiotherapy/leaflet at 12 weeks. 5.1% zero scores at 12 weeks illustrated no floor effect. Sensitivity to change was assessed at 12 weeks with mean (SD) change -4.53 (6.41), 95%CI -7.61 to -1.44 for leaflet; and -6.18 (5.59), 95%CI -9.01 to -3.30 for physiotherapy/leaflet. RMDQ mean difference (95%CI) between change from baseline to twelve weeks was 1.65(-2.46 to 5.75). Mean difference (95%CI) between groups at 12 weeks was -0.16 (-3.36 to 3.04). Participant adherence with treatment was good. No adverse events were reported. CONCLUSIONS: Both interventions were acceptable, and it is promising that they both demonstrated a trend in reducing disability in this population. A randomised controlled trial, using a different trial design, is needed to ascertain the effectiveness of combining the interventions into a stepped care intervention and comparing to a no intervention arm. Findings will guide design changes for an adequately powered randomised controlled trial, using RMDQ as the primary outcome. TRIAL REGISTRATION: ISRCTN registry 33808269.

Evaluation of current surgeon practice for patients undergoing lumbar spinal fusion surgery in the United Kingdom.

AIM: To ascertain current surgeon practice in the United Kingdom National Health Service for the management of patients undergoing lumbar spinal fusion surgery. METHODS: Descriptive survey methodology utilised an online questionnaire administered through SurveyMonkey. Eligible participants were all surgeons currently carrying out lumbar spinal fusion surgery in the National Health Service. Two previous surveys and a recent systematic review informed questions. Statistical analyses included responder characteristics and pre-planned descriptive analyses. Open question data were interpreted using thematic analysis. RESULTS: The response rate was 73.8%. Most surgeons (84%) were orthopaedic surgeons. Range of surgeon experience (1-15 years), number of operations performed in the previous 12 mo (4-250), and range of information used to predict outcome was broad. There was some consistency of practice: most patients were seen preoperatively; all surgeons ensured patients are mobile within 3 d of surgery; and there was agreement for the value of post-operative physiotherapy. However, there was considerable variability of practice: variability of protocols, duration of hospital stay, use of discharge criteria, frequency and timing of outpatient follow up, use of written patient information and outcome measures. Much variability was explained through patient-centred care, for example, 62% surgeons tailored functional advice to individual patients. CONCLUSION: Current United Kingdom surgeon practice for lumbar spinal fusion is described. The surgical procedure and patient population is diverse, and it is therefore understandable that management varies. It is evident that care should be patient-centred. However with high costs and documented patient dissatisfaction it is important that further research evaluates optimal management.