Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery.

OBJECTIVES: To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway. DESIGN: A cross-sectional, qualitative study with an interpretive descriptive design. SETTING: Academic and non-academic hospital setting in Belgium. PARTICIPANTS: 31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed. RESULTS: Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS. CONCLUSIONS: This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness. TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov (NCT03427294).

Best practice rehabilitation pathway for the management of single and double-level lumbar fusion surgery: a modified Delphi Study.

BACKGROUND: There is limited evidence to guide the rehabilitation of patients following single or double-level lumbar fusion surgery (LFS). This is reflected in extensive variability in current rehabilitation regimes and subsequent low clinical success rates, which urges a call for a consensus rehabilitation pathway. AIM: To establish consensus on the optimal pre-, peri- and postoperative rehabilitation of LFS. DESIGN: A modified Delphi Study. SETTING: Belgium and the Netherlands. POPULATION: A multidisciplinary panel of 31 experts in the field of LFS and rehabilitation participated. Nine patients validated the consensus pathway. METHODS: A three-round online Delphi questionnaire was followed by an in-person consensus meeting. In each round, experts could suggest new statements, and received group summary statistics and feedback for reconsidered statements. Consensus threshold was set at ≥75% agreement. The resulting rehabilitation pathway was validated by patients through an online questionnaire and subsequent in-person focus group. RESULTS: A total of 31 experts participated in the first online round, with 27 (87%) completing all online rounds, and 17 (55%) attending the in-person consensus meeting. Consensus was reached on 122 statements relating to pre-, peri- and postoperative rehabilitation of LFS, and validated by patients. Key components of the rehabilitation pathway included prehabilitation, education, physiotherapy in every phase, early postoperative mobilization, and little movement restrictions. Patients emphasized the need for support during the return-to-work process. CONCLUSIONS: This process resulted in 122 expert-consensus statements on best practice rehabilitation for managing LFS, validated by patients. CLINICAL REHABILITATION IMPACT: The proposed rehabilitation pathway can serve as guidance to support clinicians, reduce practice variability, and subsequently improve clinical outcomes after LFS.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis.

PURPOSE: To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis. METHODS: Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE. RESULTS: In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies). CONCLUSION: There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

Postoperative bracing after lumbar surgery: a survey amongst spinal surgeons in Belgium.

PURPOSE: Bracing is frequently prescribed following lumbar surgery for degenerative conditions. However, previous studies failed to demonstrate the advantage of postoperative lumbar bracing in both short- and long-term outcome in terms of pain, quality of life and fusion rate. The purpose of this study was to assess the prescription patterns and rationale for postoperative bracing amongst spinal surgeons in Belgium. METHODS: A 16-item online survey was distributed by email to spinal surgeons affiliated to the Spine Society of Belgium (N = 252). RESULTS: A total of 105 surgeons (42%) completed the survey. The overall bracing frequency following lumbar surgery was 38%. A brace was more often prescribed following the fusion procedures (52%) than after the non-fusion procedures (21%) (p < 0.0001). The majority of surgeons (59%) considered bracing after at least one type of lumbar surgery. Orthopaedic surgeons (73%) reported a significantly higher rate of prescribing postoperative bracing compared to neurosurgeons (44%) (p = 0.003). Pain alleviation (67%) was the main goal for prescribing a postoperative brace. A total of 42% of the surgeons aimed to improve fusion rate by bracing after lumbar fusion procedures. A quasi-equal level of the scientific literature (29%), personal experience (35%) and teaching from peers (36%) was reported to contribute on the attitudes towards prescribing bracing. CONCLUSIONS: Postoperative bracing was prescribed by Belgian spinal surgeons following more than one-third of lumbar procedures. This was underpinned by beliefs regarding pain alleviation and higher fusion rate. Interestingly, based on the scientific literature these beliefs have been demonstrated to be false. These slides can be retrieved under Electronic Supplementary Material.

The development of the Dutch version of the Fremantle Back Awareness Questionnaire.

BACKGROUND: Disturbed body perception may play a role in the aetiology of chronic low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is currently the only self-report questionnaire to assess back-specific body perception in individuals with LBP. OBJECTIVES: To perform a cross-cultural adaptation of the FreBAQ into Dutch. DESIGN: Psychometric study. METHODS: A Dutch version of the FreBAQ was generated through forward-backward translation, and was completed by 73 patients with LBP and 73 controls to assess discriminant validity. Structural validity was assessed by principal component analysis. Internal consistency was assessed by the Cronbach's alpha coefficient. Construct validity was assessed by examining the relationship with clinical measures (Numerical Rating Scale pain, Oswestry Disability Index (ODI), Tampa Scale for Kinesiophobia). Test-retest reliability was assessed in a subgroup (n = 48 with LBP and 48 controls) using intraclass correlation coefficients (ICC), standard error of measurement (SEM) and minimal detectable change (MDC 95%) RESULTS: The Dutch FreBAQ showed one component with eigenvalue >2. Cronbach's alpha values were respectively 0.82 and 0.73 for the LBP and control group. ICC values were respectively 0.69 and 0.70 for the LBP and control group. In the LBP group, the SEM was 3.9 and the MDC (95%) was 10.8. The LBP group (ODI 22 ± 21%) scored significantly higher on the Dutch FreBAQ than the control group (ODI 0%) (11 ± 7 vs. 3 ± 9, p < 0.001). Within the LBP group, higher Dutch FreBAQ scores correlated significantly with higher ODI scores (rho = 0.30, p = 0.010), although not with pain (rho = 0.10, p = 0.419) or kinesiophobia (r = 0.14, p = 0.226). CONCLUSIONS: The Dutch version of the FreBAQ can be considered as unidimensional and showed adequate internal consistency, sufficient test-retest reliability and adequate discriminant and construct validity in individuals with and without LBP. It can improve our understanding on back-specific perception in the Dutch-speaking population with LBP.

The presence of respiratory disorders in individuals with low back pain: A systematic review.

BACKGROUND: Inspiratory muscles, such as the diaphragm, play a key role in both respiration and spinal control. Therefore, diaphragm dysfunctions are often related to low back pain (LBP). However, few is known on the association between the presence of LBP and the presence of respiratory disorders (RD). OBJECTIVES: To perform a systematic review on the relation between RD and LBP. STUDY DESIGN: Systematic review. METHODS: Two reviewers searched on PubMed/MEDLINE for studies concerning LBP and RD, from 1950 up to January 2016. The search string consisted of the following key words: low back pain, dyspnea, respiratory problems, lung diseases, comorbidity, pulmonary disease, chronic obstructive, smoking, asthma, allergy, sinusitis, respiratory tract infection and hyperventilation. The aim was to evaluate a potential correlation, co-occurrence or causality between RD and LBP. RESULTS: A total of 16 articles were included. A significant correlation between the presence of LBP and the presence of RD such as dyspnea, asthma, different forms of allergy, and respiratory infections was found. No correlation was found between Chronic Obstructive Pulmonary Disease (COPD) and LBP, and no articles were found on the correlation between hyperventilation and LBP. CONCLUSIONS: This is the first study providing an overview of the literature on the relation between LBP and RD. Immunological, biomechanical, psychosocial and socio-economic factors might explain this correlation. Smoking is likely to contribute. Future studies must reveal the causative relationship. LEVEL OF EVIDENCE: Therapy, level 2a.