Journal of Occupational Rehabilitation, Vol. 4, No. 4, 1994
Early Return to Work Following an Aggressive Rehabilitation Program Initiated One Day After Spine Surgery Per O. Sjolinder 1,2 and David F. Nota I
In a program designed and conducted in a private rehabilitation center, 38 postoperative cervical or lumbar spine patients were treated with an aggressive rehabilitation regimen. The regimen included an aquatic component, stabilization and flexibility exercises, resistance and aerobic exercises, progressively difficult walks, educational sessions, and limited palliative modalities. Readiness for discharge was evaluated on the basis of clinical observations and submaximal cardiovascular testing, and a computer analysis comparing range of motion, strength, and functional capacity with normative data. No complications developed during the recovery of any patients. After an average of 3.3 days following discharge from the rehab program, 89% returned to their former occupations without restrictions. At follow-up, all patients had been working continuously at their occupation for over 25 months post-discharge. The authors conclude that, based on this retrospective analysis, this is a safe means of potentially reducing hospital time, minimizing postoperative morbidity, and restoring patients to their former occupations. These findings can only be viewed as preliminary, however, and further study in a prospective, controlled clinical trial is needed to draw definitive conclusions regarding the effectiveness of this aggressiveness rehabilitation program in the general population of postoperative spine patients. KEY WORDS: back pain; lumbar surgery; cervical surgery; postoperative rehabilitation.
INTRODUCTION Currently, 2.5 million Americans are chronically disabled by back pain 1, with back disorders being the leading cause of disability in adults under the age of 45 years 2, and the third most common cause in those over the age of 45 years. In IScandia Centrum of Rehab Medicine, 2205 Fontaine Avenue, Charlottesville, Virginia 22903. 2Correspondence should be directed to Per O. Sjolinder, Scandia Centrum of Rehab Medicine, 2205 Fontaine Avenue, Charlottesville, Virginia 22903.
211 1053-0487/94/1200-0211507.00/0 ~ 1994 PlenumPublishingCorporation
212
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previous decades, the growth rate of disability due to back problems has surpassed the population growth by a factor of 14 (Ref. 3). Today, the growth rate of low back problems is approximately 10% annually4-6. This is approximately eight times the growth rate of our population, and is partly accounted for by an increase in the population's average age. Although only about 2-5% of back pain patients require corrective surgery, this small percentage represents a significant expenditure in terms of time lost from work, compensation costs, and health care utilization 7"1~ Among adults under the age of 65 years, back and neck problems rank third among all surgical admissions 11. In 1987, about 250,000 lumbar discectomies, 102,000 lumbar fusions, and 43,000 cervical discectomies or fusions were performed in the nonfederal hospitals of the United States 12, with discectomies and lumbar fusions increasing 9.4% and 27.6%, respectively, from 1985 to 198712,13. Also, in 1987, it was reported that an estimated 200,000 to 500,000 lumbar laminectomies were performed annually, in the United States 14. Recovery from spinal surgery traditionally involves a four- to five-day hospital stay followed by four to six weeks of limited activity at home 15"18. This is generally followed by outpatient rehabilitation, and patients are usually permitted to return to work three to four months after surgery 17-21. In addition, an unsuccessful outcome after spinal disc surgery is unfortunately common, with approximately 30% of patients undergoing further surgery for the same complaints2L The failure rate for initial spinal surgery ranges from 20 to 50% worldwide 23-26, while 25,000 to 50,000 new cases of failed back surgery are estimated to occur annually in the United States alone 27. Impressive results with aggressive rehabilitation programs in chronic back pain patients who were not surgical candidates, suggested that this approach might reduce the failure rate and hasten return to work in post-surgical patients, particularly those with long-term deconditioning due to their back condition 28-31. Supporting a shortened period of post-surgical inactivity, Deyo, et al. found that two days of bed rest are as effective as seven days in patients with acute back pain 32. Also supportive of this theory, are recently reported trends toward earlier rehabilitation, and dramatically shortened periods of restricted activity, in patients recovering from cardiac surgery 33,34, ligamentous reconstruction 35,36, cesarean section 37, and surgery for multiple trauma 38,39. Taken together, this evidence led us to hypothesize that spinal surgery patients could also benefit from accelerated postoperative intervention. The often lengthy, and increasingly restrictive, preoperative course for the spine surgery patient promotes deconditioning 4~ that may continue postoperatively 41. We believed, therefore, that a program of immediate, aggressive postoperative rehabilitation would begin to reverse the physical components of the patient's condition, demonstrate to the patient his/her capabilities, promote rapid return of a stable functional level, build an enthusiastic, positive attitude, ready the patient for a quick and safe return to work, and minimize the risk of early postoperative recurrence of symptoms.
Return to Work After Spine Surgery
213
The goal of this report was to demonstrate an alternative approach to postoperative care for spine patients that offered improved quality and efficiency, and better outcome. A description of the components of the rehabilitation program, and an uncontrolled retrospective study of the outcome in a small series of patients who participated in the rehabilitation program are included.
METHODS
Thirty-eight patients, who had agreed to participate in the rehab program after their cervical or lumbar spine surgery had been performed by a neurosurgeon, between August, 1990, and February, 1991, were retrospectively reviewed. These patients included 22 males and 16 females, with a mean age of 44.9 year (range 17-76), whose occupations were as follows: 27 blue-collar workers (including 25 heavy laborers), 6 white collar workers, 1 student, and 4 retired. No restrictions regarding previous cervical or lumbar surgical procedures, or the presence of other medical conditions, were placed on program participation. The procedures were accomplished in consecutive order. Although none of the 38 patients who participated in the study were suffering from any other serious medical condition at the time of surgery, it is noteworthy that 8 had undergone previous surgery of the cervical or lumbar spine. All patients had been selected for surgery on the basis of clinical findings confirmed by objective diagnostic tests. These included computed tomography (CT) scan (7 subjects), CT scan with contrast dye (10 subjects), CT-myelogram (22 subjects), myelogram (1 subjects), electromyogram (EMG) (6 subjects), and magnetic resonance imaging (MIR) (5 subjects). All preoperative diagnoses were confirmed by surgical findings. These included herniated nucleus pulposus (20 subjects), foraminal stenosis (3 subjects), calcified disc and osteophyte (2 subjects), lumbar stenosis (6 subjects), radiculopathy secondary to bony disc fragment (2 subjects) disc bulge with nerve root compression (2 subjects), synovial cyst (1 subject), cervical radiculopathy (1 subject), herniated disc with lateral mass (1 subject), and osteophytes (1 subject). The attending neurosurgeon participated in the preoperative clinical evaluation of all study participants and, in conjunction with the radiologist, reviewed the results of all diagnostic tests. Table 1 describes the percentage of disability based on consecutive sick leave, Table 2 lists the variety of surgical procedures performed, and Table 3 summarizes the course of treatment, for these 38 patients. Onset of symptoms was defined as the date from which the patient had been off work or unable to carry out normal activities. The time from the onset of the cervical/lumbar complaints to surgery was longer than six weeks in 36 subjects (95%), six months in 23 subjects (61%), and one year in 15 subjects (39%). The mean time from symptom onset to surgery was not longer for the eight subjects who were receiving Workers' Compensation benefits at the time of surgery (M = 17.3 months, SD = 13.074), than for the study group as a whole (M = 12.8 months, SD = 12.34) (t = -1.152, p = 0.2562).
Sjolinder and Nota
214 Table 1. Disability of Patients Based on
Consecutive Sick Leave Months out of work
Number of patients
1
2
2 3
6 4
4 5 6 7
1 2 4 2
11 12 13 14 18 24 25 27 > 36 a
% disabled
}75%
}85%
1
1 1 2 3 1 1 1 6
}99%
al patient, 7 years; 2 patients, 10 years; 2 patients, 12 years; 1 patient, 15 years.
Table 2. Operative Procedures Performed on 38 Rehab Patients
Procedure
Number of patients
Cervical (C4-7) Lumbar (L1-S1)
11 27
Laminectomy (partial, hemi, total) Disceetomy Foraminotomy Fusion Facetectomy Pedicle removal Synovial cyst removal Fasciectomy
38 a 33b 3 2 1 1 1 1
Level/Number of Procedures Single level/si'ngle procedure Single level/multiple procedures Multiple level/multiple procedures
1 27 c 10d
alncludes one multiple-level laminectomy. blntraoperative chymopapain chemonucleolysis of lumbar discs was performed in conjunction with discectomy/hemilaminectomy in 9 patients. Clncludes one fusion. dlncludes one fusion.
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215
Table 3. History of 38 Patients Prior to Rehab Program
Patient data
Mean
Std. dev.
Range
12.80
12.34
1->36 a
Number of preoperative physician visits
3.42
1.43
1-7
Number of preoperative diagnostic testsb
4.32
2.24
1-10
Time from surgery to hospital discharge (days)
1.39
0.55
1-3
Time from surgery to rehab program (days)
1.92
1.60
1-7
Time of symptom onset to surgery (months)
al patient, 7 years; 2 patients, 10 years; 2 patients, 12 years; 1 patient, 15 years. bMRI, CT, myelogram, EMG.
This rehabilitation program included aquatic exercises requiring immersion of the wound. To reduce the risk of infection in the participants, all surgical incisions were sutured with a subcuticular stitch to aid in rapid wound closure. To minimize Workers' Compensation expenditures, by more effectively utilizing a higher percentage of the out of work time and decreasing time spent in travel, a residential option was offered to study subjects at a hotel adjacent to the rehab center. Transportation was provided between the hotel and the rehab center. To minimize risk of reinjury due to travel, all 38 subjects were instructed to stay in the hotel during the first week of their program, and not to drive. Patients who resided within 30 miles of the center were permitted to commute daily after the first week. Free time activity was otherwise unrestricted from the first postoperative day, however patients were instructed not to "over do" outside of their rehab program during the first few days. Rehabilitation sessions were held Monday through Friday. Study subjects began the rehab program the day after surgery (24 subjects), unless the surgery was performed on Friday, in which case it was begun on the following Monday (14 subjects). Patients whose surgery was done Monday through Thursday were discharged from the hospital on the first postoperative day, to immediately check into the hotel and begin admission procedures in the rehabilitation center. Friday's surgical patients were admitted to the rehab center on Monday morning to begin evaluation and rehabilitation. On admission to the rehab center, a standardized evaluation was performed by a physical tJaerapist, consisting of a medical history and physical examination, and a waterproof sterile transparent dressing (Bioclusive, Johnson & Johnson Medical, Arlington, Texas) was applied over the patient's surgical incision. The physical therapist who had conducted the examination, then structured an individualized treatment program for the patient based on the problem elements identified. Typically lasting 2 to 4 hours on the first day (day of admission), it was rapidly lengthened over the next one to two days, reaching a maximum of 8 hours daily. In all
216
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cases, that same physical therapist worked with the patient throughout the rehab program, following the patient's progress, and adjusting the regimen as needed. Dressings were initially changed daily by the patient's physical therapist, who assessed healing and performed wound care as needed. As the program progressed, the frequency of the dressing changes were guided by incisional healing, with dressings permanently removed between postoperative days 10 and 14. Ice and interferential electrical stimulation were administered for postoperative pain and swelling as needed. Additional modalities and treatments included moist heat, soft tissue mobilization, 90/90 traction (Back & Neck Trac, Lossing Orthopedic, Minneapolis, Minnesota), 3-D auto-traction, ultrasound, and phonophoresis. Patients received no prescription medication for postoperative pain, either in the hospital, or during the subsequent medical rehabilitation program. Although each patient's treatment regimen was individualized according to his/her specific needs and capabilities, all regimens had several important components in common, as described below. 1. Specific stabilization and flexibility exercises included flexion-extension, lateral bending, and rotation within a ten-degree range that we term "functional neutral". The two-fold goal was to reactivate the musculature in the affected area, to achieve functional stabilization and enhance the flexibility of certain muscle groups identified by the treating physical therapist. 2. In the aquatic program, the patient took advantage of the supportive properties of water, while submerged to a level above the incision, in a pool with the temperature maintained at 85 degrees Fahrenheit. The pool component generally began on the day of admission, and over the course of the treatment regimen, the patient progressed from once daily sessions of exercises without resistance, to twice daily sessions with resistance and functional activities. This portion included walking and range of motion exercises to reduce muscle spasm, allowing an increased range of motion in the affected area of the spine, and providing general conditioning and strengthening. 3. Resistance and aerobic exercises, involving high repetition and low loads, were performed in the gym with the use of ergonomically designed equipment that incorporated safe positioning. With the goal of strengthening and conditioning problem areas and optimizing cardiovascular function, the exercises involved the use of isotonic resistance equipment (Norsk, Norway), pulley systems (Saba, Norway), Medical Exercise Therapy equipment (Saba, Norway), and functional closed kinetic chain activities. Additional cardiovascular training was achieved with the use of bike ergometers (Monarch, Sweden; Fitron Cycle Ergometer, Cybex Isokinetic Systems, Ronkonkoma, New York), an upper body ergometer (UBE Ergometer, Cybex Isokinetic Systems, Ronkonkoma, New York), a Nordic Track (Nordic Track Pro, Chaska, Minnesota), a treadmill (Coursetter OR4 Treadmill, Performance USA, Dallas, Texas), and a Stairmaster (Stairmaster 4000 PT, Stairmaster Exercise System, Tulsa, Oklahoma). During the first three to four days, range of motion at the operative level was kept stable and within "functional neutral", while the patient worked the spinal
Return to Work After Spine Surgery
217
postural muscles through a more distal approach. The patient later advanced to dynamic functional exercises, increasing spinal range of motion in the affected area. He/she was then progressed from exercises with no resistance, to those with progressive submaximal resistance, including the use of free weights. Functional and work-related activities, per the patient's job description, were incorporated into all phases of the rehabilitation process. 4. An individualized, weekly patient evaluation quantified the functional results. This evaluation assessed the following parameters: 1) submaximal cardiovascular performance, using a Fitron Bike, and steady state heart rate measurement 2) computerized analysis of active range of motion, using the Arcon-AROM system dual inclinometer (Arcon, Williamsburg, Virginia), and American Medical Association norms 42, 3) computerized analysis of lift strength, using the Arcon-ST computerized lift strength system, and NIOSH norms43; 4) balance and coordination, using a balance beam; 5) weight and vital signs (heart rate, blood pressure); 6) submaximal extremity strength testing (Norsk Isotonic Sequence Training System, Norway); 7) computerized assessment of isometric trunk muscle strength and endurance in lumbar patients, using a computerized strength training and measurement system (Dynatrac, Baltimore Therapeutic Equipment); and 8) computerized analysis of pinch and grip strength in cervical patients (Arcon pinch and grip strength system) and AMA norms 42,44. To ensure proper readings, all computerized testing equipment was recalibrated regularly according to the manufacturers' recommendation and instructions. Results of this evaluation, in combination with clinical observations of improving functional capacity, were used to upgrade the patient's individual regimen and to assess readiness for discharge. To this end, it was imperative to assess those factors that exhibited the deleterious effects of symptom prolongation, that we believed to be of significance in this patient group. The choice of elements was based on the natural deconditioning experienced by these patients, that we then believed to be a factor in the patient's ability to return early and safely to work. All patients were individually assessed, based on job activities, and were required to achieve a medium to low risk level prior to returning to work. 5. Educational sessions on anatomy and physiology, ergonomics, posture, nutrition, and relaxation techniques were conducted twice weekly by the clinical staff. 6. Finally, patients were taken on supervised group walks, over variable terrain, on the grounds surrounding the rehabilitation center. Beginning with short walks one or two days postoperatively, by the end of the first week, they progressed to one-mile walks twice daily. During all rehabilitation sessions, physical therapists and adjunct staff closely monitored the subjects to ensure the proper, safe performance of all activities. Patients were initially encouraged to engage in activity up to their pain level, but were instructed to distinguish between muscle soreness and pain specific to the affected area. Once they made this distinction, they were encouraged to work through the muscle soreness, modifying their exercises for specific pain.
218
Sjolinder and Nora
Because the patient's psychological state was considered an influential component in the success of the rehabilitation program, the staff made every effort to engender a positive outlook in the subjects and to encourage maximum participation. Care was therefore taken to avoid reference to pain, instead directing attention toward improvements in function. Patients were discharged from the rehabilitation program when it was determined that they had achieved a functional level that allowed safe resumption of work at their former occupation, with or without modifications or restrictions. To assure that the subjects had achieved sufficient function to return to work safely, each patient's job description and specific job requirements were considered in combination with the strength and endurance values and level of function achieved by the subject, and compared to normative data (American Medical Association (AMA) and National Institute for Occupational Safety and Health (NIOSH)) describing what is estimated to be required for that job performance 42,44,45. An objective measure was obtained by comparing results from a computerized analysis of the patient's range of motion, pinch and grip strength (for cervical patients) using the equipment described in the treatment regimen, and isometric lifting strength with normative data 42"4~. The computer analysis was used in conjunction with the results of submaximal cardiovascular testing and the clinical observations of the treating therapist, over the three week period. In general, patients had to demonstrate average to above-average strength, compared with AMA and NIOSH norms 42,44,45, before being discharged and permitted to return to work. However, all patients were expected to make appropriate modifications in techniques of performing required job functions and daily living activities (i.e. appropriate posturing, supported sitting, safe lifting techniques), based on information imparted during the education lectures. The 38 subjects were re-examined and retested by physical therapists at the rehab center four to six weeks postoperatively. Range of motion, pinch and grip strength (cervical patients), and isometric lifting strength were clinically evaluated, and the values were compared against normative data (AMA, NIOSH) 42-45. Further follow-up involved telephone contact an average of 26 months after program discharge, by the physical therapist who had been in charge of their care. Using a standardized questionnaire, the interviewer asked each patient a set of questions regarding his/her return to work or full activity, lost work days, need for pain medication, recurrence of preoperative symptoms, physician visits, diagnostic tests, reoperation for the initial complaint, or subsequent rehabilitation. The two criteria used to determine a successful outcome in subjects who had participated in the rehab program were a rapid (15-20 treatment days) return to work at the preoperative occupation without restriction (or return to full unrestricted activity in the case of retirees), and the ability to maintain this status without interruption to the time of final follow-up interview. Statistical evaluation of comparative values were accomplished using the Student's t-test and The Fisher Exact Test.
Return to Work After Spine Surgery
219
RESULTS The rehabilitation program results are summarized in Tables 4 and 5. The hospital stay for the 38 patients ranged from one to three days, with only one patient remaining three days due to bladder dysfunction. The patients were admitted to the rehabilitation program an average of 1.9 days after surgery. Thirty-five were admitted directly from the hospital to the rehabilitation program, while three others, each discharged from the hospital one day after surgery, elected to stay home for four to six days before beginning the rehabilitation program.
Rehab Program Compliance Participation in the rehabilitation program averaged 15.3 days, excluding weekends. One patient left against medical advice after nine days, and one was transferred to another facility after 17 days. As these two patients did not meet the "successful patient" criteria, they were included as part of the total number of 4 treatment failures.
Table 4. Postoperative Outcome of Rehab Program Patient data
Mean
Std. dev.
Range
Length of participation in rehabilitation program (days)
15.30
3.35
6-21
% of patients returning to same unrestricted work (RTW)
89%
% of patients returning to light duty
0% 20.05
3.97
10-29
3.24
4.02
1-25
Time from surgery to return to work (RTW) (days) Time from program discharge to return to work (days) # of diagnostic tests after rehabilitation
0
Time from surgery to final follow-up (months)
26.89
1.78
23.5~0.5
Time from rehabilitation discharge to final follow-up (months)
26.37
1.76
23-30
% of patients maintaining unrestricted, uninterrupted work at final follow-up
89% (34/38)
% of unsuccessful rehabilitation (long term disability)
11% (4/38)
220
Sjolinder and Nota
Table 5. Patient Progress on Performance Tests from Initial Evaluation to Discharge Evaluationa
Evaluation mean
Discharge mean
Difference mean
t
Pain level scale 0-10
5.07 (3.06)
1.48 (1.04)
3.59 (2.54)
7.60
Early Return to Work Following an Aggressive Rehabilitation Program Initiated One Day After Spine Surgery Per O. Sjolinder 1,2 and David F. Nota I
In a program designed and conducted in a private rehabilitation center, 38 postoperative cervical or lumbar spine patients were treated with an aggressive rehabilitation regimen. The regimen included an aquatic component, stabilization and flexibility exercises, resistance and aerobic exercises, progressively difficult walks, educational sessions, and limited palliative modalities. Readiness for discharge was evaluated on the basis of clinical observations and submaximal cardiovascular testing, and a computer analysis comparing range of motion, strength, and functional capacity with normative data. No complications developed during the recovery of any patients. After an average of 3.3 days following discharge from the rehab program, 89% returned to their former occupations without restrictions. At follow-up, all patients had been working continuously at their occupation for over 25 months post-discharge. The authors conclude that, based on this retrospective analysis, this is a safe means of potentially reducing hospital time, minimizing postoperative morbidity, and restoring patients to their former occupations. These findings can only be viewed as preliminary, however, and further study in a prospective, controlled clinical trial is needed to draw definitive conclusions regarding the effectiveness of this aggressiveness rehabilitation program in the general population of postoperative spine patients. KEY WORDS: back pain; lumbar surgery; cervical surgery; postoperative rehabilitation.
INTRODUCTION Currently, 2.5 million Americans are chronically disabled by back pain 1, with back disorders being the leading cause of disability in adults under the age of 45 years 2, and the third most common cause in those over the age of 45 years. In IScandia Centrum of Rehab Medicine, 2205 Fontaine Avenue, Charlottesville, Virginia 22903. 2Correspondence should be directed to Per O. Sjolinder, Scandia Centrum of Rehab Medicine, 2205 Fontaine Avenue, Charlottesville, Virginia 22903.
211 1053-0487/94/1200-0211507.00/0 ~ 1994 PlenumPublishingCorporation
212
Sjolinder and Nota
previous decades, the growth rate of disability due to back problems has surpassed the population growth by a factor of 14 (Ref. 3). Today, the growth rate of low back problems is approximately 10% annually4-6. This is approximately eight times the growth rate of our population, and is partly accounted for by an increase in the population's average age. Although only about 2-5% of back pain patients require corrective surgery, this small percentage represents a significant expenditure in terms of time lost from work, compensation costs, and health care utilization 7"1~ Among adults under the age of 65 years, back and neck problems rank third among all surgical admissions 11. In 1987, about 250,000 lumbar discectomies, 102,000 lumbar fusions, and 43,000 cervical discectomies or fusions were performed in the nonfederal hospitals of the United States 12, with discectomies and lumbar fusions increasing 9.4% and 27.6%, respectively, from 1985 to 198712,13. Also, in 1987, it was reported that an estimated 200,000 to 500,000 lumbar laminectomies were performed annually, in the United States 14. Recovery from spinal surgery traditionally involves a four- to five-day hospital stay followed by four to six weeks of limited activity at home 15"18. This is generally followed by outpatient rehabilitation, and patients are usually permitted to return to work three to four months after surgery 17-21. In addition, an unsuccessful outcome after spinal disc surgery is unfortunately common, with approximately 30% of patients undergoing further surgery for the same complaints2L The failure rate for initial spinal surgery ranges from 20 to 50% worldwide 23-26, while 25,000 to 50,000 new cases of failed back surgery are estimated to occur annually in the United States alone 27. Impressive results with aggressive rehabilitation programs in chronic back pain patients who were not surgical candidates, suggested that this approach might reduce the failure rate and hasten return to work in post-surgical patients, particularly those with long-term deconditioning due to their back condition 28-31. Supporting a shortened period of post-surgical inactivity, Deyo, et al. found that two days of bed rest are as effective as seven days in patients with acute back pain 32. Also supportive of this theory, are recently reported trends toward earlier rehabilitation, and dramatically shortened periods of restricted activity, in patients recovering from cardiac surgery 33,34, ligamentous reconstruction 35,36, cesarean section 37, and surgery for multiple trauma 38,39. Taken together, this evidence led us to hypothesize that spinal surgery patients could also benefit from accelerated postoperative intervention. The often lengthy, and increasingly restrictive, preoperative course for the spine surgery patient promotes deconditioning 4~ that may continue postoperatively 41. We believed, therefore, that a program of immediate, aggressive postoperative rehabilitation would begin to reverse the physical components of the patient's condition, demonstrate to the patient his/her capabilities, promote rapid return of a stable functional level, build an enthusiastic, positive attitude, ready the patient for a quick and safe return to work, and minimize the risk of early postoperative recurrence of symptoms.
Return to Work After Spine Surgery
213
The goal of this report was to demonstrate an alternative approach to postoperative care for spine patients that offered improved quality and efficiency, and better outcome. A description of the components of the rehabilitation program, and an uncontrolled retrospective study of the outcome in a small series of patients who participated in the rehabilitation program are included.
METHODS
Thirty-eight patients, who had agreed to participate in the rehab program after their cervical or lumbar spine surgery had been performed by a neurosurgeon, between August, 1990, and February, 1991, were retrospectively reviewed. These patients included 22 males and 16 females, with a mean age of 44.9 year (range 17-76), whose occupations were as follows: 27 blue-collar workers (including 25 heavy laborers), 6 white collar workers, 1 student, and 4 retired. No restrictions regarding previous cervical or lumbar surgical procedures, or the presence of other medical conditions, were placed on program participation. The procedures were accomplished in consecutive order. Although none of the 38 patients who participated in the study were suffering from any other serious medical condition at the time of surgery, it is noteworthy that 8 had undergone previous surgery of the cervical or lumbar spine. All patients had been selected for surgery on the basis of clinical findings confirmed by objective diagnostic tests. These included computed tomography (CT) scan (7 subjects), CT scan with contrast dye (10 subjects), CT-myelogram (22 subjects), myelogram (1 subjects), electromyogram (EMG) (6 subjects), and magnetic resonance imaging (MIR) (5 subjects). All preoperative diagnoses were confirmed by surgical findings. These included herniated nucleus pulposus (20 subjects), foraminal stenosis (3 subjects), calcified disc and osteophyte (2 subjects), lumbar stenosis (6 subjects), radiculopathy secondary to bony disc fragment (2 subjects) disc bulge with nerve root compression (2 subjects), synovial cyst (1 subject), cervical radiculopathy (1 subject), herniated disc with lateral mass (1 subject), and osteophytes (1 subject). The attending neurosurgeon participated in the preoperative clinical evaluation of all study participants and, in conjunction with the radiologist, reviewed the results of all diagnostic tests. Table 1 describes the percentage of disability based on consecutive sick leave, Table 2 lists the variety of surgical procedures performed, and Table 3 summarizes the course of treatment, for these 38 patients. Onset of symptoms was defined as the date from which the patient had been off work or unable to carry out normal activities. The time from the onset of the cervical/lumbar complaints to surgery was longer than six weeks in 36 subjects (95%), six months in 23 subjects (61%), and one year in 15 subjects (39%). The mean time from symptom onset to surgery was not longer for the eight subjects who were receiving Workers' Compensation benefits at the time of surgery (M = 17.3 months, SD = 13.074), than for the study group as a whole (M = 12.8 months, SD = 12.34) (t = -1.152, p = 0.2562).
Sjolinder and Nota
214 Table 1. Disability of Patients Based on
Consecutive Sick Leave Months out of work
Number of patients
1
2
2 3
6 4
4 5 6 7
1 2 4 2
11 12 13 14 18 24 25 27 > 36 a
% disabled
}75%
}85%
1
1 1 2 3 1 1 1 6
}99%
al patient, 7 years; 2 patients, 10 years; 2 patients, 12 years; 1 patient, 15 years.
Table 2. Operative Procedures Performed on 38 Rehab Patients
Procedure
Number of patients
Cervical (C4-7) Lumbar (L1-S1)
11 27
Laminectomy (partial, hemi, total) Disceetomy Foraminotomy Fusion Facetectomy Pedicle removal Synovial cyst removal Fasciectomy
38 a 33b 3 2 1 1 1 1
Level/Number of Procedures Single level/si'ngle procedure Single level/multiple procedures Multiple level/multiple procedures
1 27 c 10d
alncludes one multiple-level laminectomy. blntraoperative chymopapain chemonucleolysis of lumbar discs was performed in conjunction with discectomy/hemilaminectomy in 9 patients. Clncludes one fusion. dlncludes one fusion.
Return to Work After Spine Surgery
215
Table 3. History of 38 Patients Prior to Rehab Program
Patient data
Mean
Std. dev.
Range
12.80
12.34
1->36 a
Number of preoperative physician visits
3.42
1.43
1-7
Number of preoperative diagnostic testsb
4.32
2.24
1-10
Time from surgery to hospital discharge (days)
1.39
0.55
1-3
Time from surgery to rehab program (days)
1.92
1.60
1-7
Time of symptom onset to surgery (months)
al patient, 7 years; 2 patients, 10 years; 2 patients, 12 years; 1 patient, 15 years. bMRI, CT, myelogram, EMG.
This rehabilitation program included aquatic exercises requiring immersion of the wound. To reduce the risk of infection in the participants, all surgical incisions were sutured with a subcuticular stitch to aid in rapid wound closure. To minimize Workers' Compensation expenditures, by more effectively utilizing a higher percentage of the out of work time and decreasing time spent in travel, a residential option was offered to study subjects at a hotel adjacent to the rehab center. Transportation was provided between the hotel and the rehab center. To minimize risk of reinjury due to travel, all 38 subjects were instructed to stay in the hotel during the first week of their program, and not to drive. Patients who resided within 30 miles of the center were permitted to commute daily after the first week. Free time activity was otherwise unrestricted from the first postoperative day, however patients were instructed not to "over do" outside of their rehab program during the first few days. Rehabilitation sessions were held Monday through Friday. Study subjects began the rehab program the day after surgery (24 subjects), unless the surgery was performed on Friday, in which case it was begun on the following Monday (14 subjects). Patients whose surgery was done Monday through Thursday were discharged from the hospital on the first postoperative day, to immediately check into the hotel and begin admission procedures in the rehabilitation center. Friday's surgical patients were admitted to the rehab center on Monday morning to begin evaluation and rehabilitation. On admission to the rehab center, a standardized evaluation was performed by a physical tJaerapist, consisting of a medical history and physical examination, and a waterproof sterile transparent dressing (Bioclusive, Johnson & Johnson Medical, Arlington, Texas) was applied over the patient's surgical incision. The physical therapist who had conducted the examination, then structured an individualized treatment program for the patient based on the problem elements identified. Typically lasting 2 to 4 hours on the first day (day of admission), it was rapidly lengthened over the next one to two days, reaching a maximum of 8 hours daily. In all
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cases, that same physical therapist worked with the patient throughout the rehab program, following the patient's progress, and adjusting the regimen as needed. Dressings were initially changed daily by the patient's physical therapist, who assessed healing and performed wound care as needed. As the program progressed, the frequency of the dressing changes were guided by incisional healing, with dressings permanently removed between postoperative days 10 and 14. Ice and interferential electrical stimulation were administered for postoperative pain and swelling as needed. Additional modalities and treatments included moist heat, soft tissue mobilization, 90/90 traction (Back & Neck Trac, Lossing Orthopedic, Minneapolis, Minnesota), 3-D auto-traction, ultrasound, and phonophoresis. Patients received no prescription medication for postoperative pain, either in the hospital, or during the subsequent medical rehabilitation program. Although each patient's treatment regimen was individualized according to his/her specific needs and capabilities, all regimens had several important components in common, as described below. 1. Specific stabilization and flexibility exercises included flexion-extension, lateral bending, and rotation within a ten-degree range that we term "functional neutral". The two-fold goal was to reactivate the musculature in the affected area, to achieve functional stabilization and enhance the flexibility of certain muscle groups identified by the treating physical therapist. 2. In the aquatic program, the patient took advantage of the supportive properties of water, while submerged to a level above the incision, in a pool with the temperature maintained at 85 degrees Fahrenheit. The pool component generally began on the day of admission, and over the course of the treatment regimen, the patient progressed from once daily sessions of exercises without resistance, to twice daily sessions with resistance and functional activities. This portion included walking and range of motion exercises to reduce muscle spasm, allowing an increased range of motion in the affected area of the spine, and providing general conditioning and strengthening. 3. Resistance and aerobic exercises, involving high repetition and low loads, were performed in the gym with the use of ergonomically designed equipment that incorporated safe positioning. With the goal of strengthening and conditioning problem areas and optimizing cardiovascular function, the exercises involved the use of isotonic resistance equipment (Norsk, Norway), pulley systems (Saba, Norway), Medical Exercise Therapy equipment (Saba, Norway), and functional closed kinetic chain activities. Additional cardiovascular training was achieved with the use of bike ergometers (Monarch, Sweden; Fitron Cycle Ergometer, Cybex Isokinetic Systems, Ronkonkoma, New York), an upper body ergometer (UBE Ergometer, Cybex Isokinetic Systems, Ronkonkoma, New York), a Nordic Track (Nordic Track Pro, Chaska, Minnesota), a treadmill (Coursetter OR4 Treadmill, Performance USA, Dallas, Texas), and a Stairmaster (Stairmaster 4000 PT, Stairmaster Exercise System, Tulsa, Oklahoma). During the first three to four days, range of motion at the operative level was kept stable and within "functional neutral", while the patient worked the spinal
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postural muscles through a more distal approach. The patient later advanced to dynamic functional exercises, increasing spinal range of motion in the affected area. He/she was then progressed from exercises with no resistance, to those with progressive submaximal resistance, including the use of free weights. Functional and work-related activities, per the patient's job description, were incorporated into all phases of the rehabilitation process. 4. An individualized, weekly patient evaluation quantified the functional results. This evaluation assessed the following parameters: 1) submaximal cardiovascular performance, using a Fitron Bike, and steady state heart rate measurement 2) computerized analysis of active range of motion, using the Arcon-AROM system dual inclinometer (Arcon, Williamsburg, Virginia), and American Medical Association norms 42, 3) computerized analysis of lift strength, using the Arcon-ST computerized lift strength system, and NIOSH norms43; 4) balance and coordination, using a balance beam; 5) weight and vital signs (heart rate, blood pressure); 6) submaximal extremity strength testing (Norsk Isotonic Sequence Training System, Norway); 7) computerized assessment of isometric trunk muscle strength and endurance in lumbar patients, using a computerized strength training and measurement system (Dynatrac, Baltimore Therapeutic Equipment); and 8) computerized analysis of pinch and grip strength in cervical patients (Arcon pinch and grip strength system) and AMA norms 42,44. To ensure proper readings, all computerized testing equipment was recalibrated regularly according to the manufacturers' recommendation and instructions. Results of this evaluation, in combination with clinical observations of improving functional capacity, were used to upgrade the patient's individual regimen and to assess readiness for discharge. To this end, it was imperative to assess those factors that exhibited the deleterious effects of symptom prolongation, that we believed to be of significance in this patient group. The choice of elements was based on the natural deconditioning experienced by these patients, that we then believed to be a factor in the patient's ability to return early and safely to work. All patients were individually assessed, based on job activities, and were required to achieve a medium to low risk level prior to returning to work. 5. Educational sessions on anatomy and physiology, ergonomics, posture, nutrition, and relaxation techniques were conducted twice weekly by the clinical staff. 6. Finally, patients were taken on supervised group walks, over variable terrain, on the grounds surrounding the rehabilitation center. Beginning with short walks one or two days postoperatively, by the end of the first week, they progressed to one-mile walks twice daily. During all rehabilitation sessions, physical therapists and adjunct staff closely monitored the subjects to ensure the proper, safe performance of all activities. Patients were initially encouraged to engage in activity up to their pain level, but were instructed to distinguish between muscle soreness and pain specific to the affected area. Once they made this distinction, they were encouraged to work through the muscle soreness, modifying their exercises for specific pain.
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Because the patient's psychological state was considered an influential component in the success of the rehabilitation program, the staff made every effort to engender a positive outlook in the subjects and to encourage maximum participation. Care was therefore taken to avoid reference to pain, instead directing attention toward improvements in function. Patients were discharged from the rehabilitation program when it was determined that they had achieved a functional level that allowed safe resumption of work at their former occupation, with or without modifications or restrictions. To assure that the subjects had achieved sufficient function to return to work safely, each patient's job description and specific job requirements were considered in combination with the strength and endurance values and level of function achieved by the subject, and compared to normative data (American Medical Association (AMA) and National Institute for Occupational Safety and Health (NIOSH)) describing what is estimated to be required for that job performance 42,44,45. An objective measure was obtained by comparing results from a computerized analysis of the patient's range of motion, pinch and grip strength (for cervical patients) using the equipment described in the treatment regimen, and isometric lifting strength with normative data 42"4~. The computer analysis was used in conjunction with the results of submaximal cardiovascular testing and the clinical observations of the treating therapist, over the three week period. In general, patients had to demonstrate average to above-average strength, compared with AMA and NIOSH norms 42,44,45, before being discharged and permitted to return to work. However, all patients were expected to make appropriate modifications in techniques of performing required job functions and daily living activities (i.e. appropriate posturing, supported sitting, safe lifting techniques), based on information imparted during the education lectures. The 38 subjects were re-examined and retested by physical therapists at the rehab center four to six weeks postoperatively. Range of motion, pinch and grip strength (cervical patients), and isometric lifting strength were clinically evaluated, and the values were compared against normative data (AMA, NIOSH) 42-45. Further follow-up involved telephone contact an average of 26 months after program discharge, by the physical therapist who had been in charge of their care. Using a standardized questionnaire, the interviewer asked each patient a set of questions regarding his/her return to work or full activity, lost work days, need for pain medication, recurrence of preoperative symptoms, physician visits, diagnostic tests, reoperation for the initial complaint, or subsequent rehabilitation. The two criteria used to determine a successful outcome in subjects who had participated in the rehab program were a rapid (15-20 treatment days) return to work at the preoperative occupation without restriction (or return to full unrestricted activity in the case of retirees), and the ability to maintain this status without interruption to the time of final follow-up interview. Statistical evaluation of comparative values were accomplished using the Student's t-test and The Fisher Exact Test.
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RESULTS The rehabilitation program results are summarized in Tables 4 and 5. The hospital stay for the 38 patients ranged from one to three days, with only one patient remaining three days due to bladder dysfunction. The patients were admitted to the rehabilitation program an average of 1.9 days after surgery. Thirty-five were admitted directly from the hospital to the rehabilitation program, while three others, each discharged from the hospital one day after surgery, elected to stay home for four to six days before beginning the rehabilitation program.
Rehab Program Compliance Participation in the rehabilitation program averaged 15.3 days, excluding weekends. One patient left against medical advice after nine days, and one was transferred to another facility after 17 days. As these two patients did not meet the "successful patient" criteria, they were included as part of the total number of 4 treatment failures.
Table 4. Postoperative Outcome of Rehab Program Patient data
Mean
Std. dev.
Range
Length of participation in rehabilitation program (days)
15.30
3.35
6-21
% of patients returning to same unrestricted work (RTW)
89%
% of patients returning to light duty
0% 20.05
3.97
10-29
3.24
4.02
1-25
Time from surgery to return to work (RTW) (days) Time from program discharge to return to work (days) # of diagnostic tests after rehabilitation
0
Time from surgery to final follow-up (months)
26.89
1.78
23.5~0.5
Time from rehabilitation discharge to final follow-up (months)
26.37
1.76
23-30
% of patients maintaining unrestricted, uninterrupted work at final follow-up
89% (34/38)
% of unsuccessful rehabilitation (long term disability)
11% (4/38)
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Table 5. Patient Progress on Performance Tests from Initial Evaluation to Discharge Evaluationa
Evaluation mean
Discharge mean
Difference mean
t
Pain level scale 0-10
5.07 (3.06)
1.48 (1.04)
3.59 (2.54)
7.60
