Back in Action

20 April, 2011

Many people live with chronic low back pain and have come to accept a certain level of discomfort and restriction of movement.  For some, relief can come in the form of physiotherapy, designed specifically to develop core strength and provide a solid support system for the lumbar spine.

There are many causes of low back pain, lumbar disc prolaspe or herniation being one.  If a herniated disc results in nerve root compression, the patient typically suffers servere leg pain, loss of mobility and reduced sensation in one or both legs.  Physiotherapeutic care may remain an option, but surgical intervention (a lumbar discectomy) is often considered.

Despite being regarded as a successful treatment for lumbar disc herniation, many patients continue to experience symptoms after a discectomy.   Hence for many patients, surgery is only a first step on the road to recovery and a programme of rehabilitation must follow.

The aim of this review is to establish whether an intensive exercise programme should form an integral part of rehabilitation following first-time lumbar discectomy, and if so what format that exercise programme should take, how soon after surgery it should begin and how long it should last.

 

Method

A literature search was conducted using PubMed and supplemented by the same search in TheLancet.com, Google Scholar and screening of references in identified studies.  Both randomised and non-randomised controlled clinical trials on any type of active rehabilitation programme following first-time lumbar discectomy were included.  The reviewer then applied specific inclusion criteria before completing both a methodological quality assessment and a clinical relevance assessment of the studies considered.

Results

14 trials, 13 randomised clinical trials (RCTs) and 1 non-randomised controlled clinical trial (CCT), were included in the systematic review.  Seven RCTs and the CCT were classifed as being of high quality, that is they demonstrated a high methodological approach and a clinical relevance score of 3 or more out of 5.  Six RCTs were classified as being of low quality.  Without exception and irrespective of when started, the 14 studies considered show that exercise of some form brings about improvement in pain, disability and physical function in first-time discectomy patients without increasing the re-herniation or re-operation rates.

Starting active rehabilitation as soon as possible achieves good results, with exercise becoming progressively more intensive.  Not only does this produce physical benefit for the patient, but prevents a fear of activity developing and psychological barriers to physical exercise becoming insurmountable.

Furthermore, it can generally be observed that the longer the period of exercise intervention the more permanent the pain relief.  Specifically, 12-week intensive exercise programmes indicate pain levels that are at least stable post-intervention, i.e. pain does not return to pre-intervention levels once the exercise programme is stopped.

Conclusion

A progressive and intensive rehabilitation programme which

  • focuses on strengthening back and abdominal muscles, improving lumbar stability and increasing spinal mobility
  • starts immediately after surgery and builds progressively
  • lasts for at least 12 weeks

has a greater impact on pain, disability, physical function and psychological status.  Moreover, the improvement in pain level seems to be lasting.

Patients may not need constant supervision during their rehabilitation.  However they will benefit from clear, adequate and consistent guidance from surgeons and physiotherapists alike which reflects current research into postoperative care.

For a patient to understand what his/her responsibilities are with respect to rehabilitation, and knowing what results can be achieved within what time span can be a very powerful motivational tool which should not be underestimated by professional carers.

To view the study in full, follow this link: Back in Action.