An Exploration of Preoperative Musculoskeletal Rehabilitation in the Treatment of Lumbar Discectomy Patients

Abstract

Background: Rehabilitation, including education and/or exercise, is thought to improve outcomes following lumbar discectomy (LD). It is typically delivered in the post-operative setting, although there is increasing interest in delivery in the preoperative setting. The aims of the work presented in the thesis were: i) to evaluate the current evidence base relating to preoperative rehabilitation for LD patients; ii) to identify current UK practice in the rehabilitation of LD patients; iii) to determine patients’ and clinicians’ views about preoperative rehabilitation for LD; and iv) to compare the outcomes of patients receiving preoperative and post-operative rehabilitation for LD. Patients and methods: i) A scoping review was conducted to evaluate the evidence base for preoperative rehabilitation in LD patients. ii) Physiotherapists treating LD patients in UK centres were identified through professional mailing lists and asked to complete an online questionnaire about rehabilitation for LD patients. iii) A retrospective review of patient-reported outcomes in 298 patients who had had spine surgery at the Salford Royal NHS Foundation Trust (SRFT) between December 2016 and March 2019 was undertaken using data collected as part of the Spine Tango Registry. Outcomes, including back and leg pain and a composite outcome (Core Outcomes Index Score (COMI)), were assessed prior to and at 6- and 12-month intervals following surgery. The outcomes of LD patients attending preoperative rehabilitation classes were compared with those who were invited but did not attend. iv) A purposive sample of LD patients attending the preoperative rehabilitation class, LD patients who did not attend from October 2019 to March 2020, and clinicians involved in the class delivery were invited to participate in focus groups to discuss their views and perspectives on rehabilitation. Findings: i) There was insufficient evidence to inform guidelines on preoperative rehabilitation outcomes for patients undergoing LD. ii) There was variation in the content and timing of rehabilitation for LD patients. Rehabilitation was provided preoperatively in 6 of 17 centres that participated in the survey. Preoperative rehabilitation focused mainly on education, while post-operative outpatient rehabilitation focused more on exercises. iii) There was no important difference in patient-reported outcomes in LD patients who attended and LD patients who did not attend preoperative rehabilitation, although, compared to those who did not have preoperative rehabilitation, those who did were more likely to achieve a minimally important difference in the COMI score post-operatively at 12 months (76% vs 66%). iv) The preoperative class was thought to be very helpful by clinicians, particularly as a solution for staffing problems; the class was thought to be very useful by patients, both in terms of the content that they needed and as preparation for surgery. Patients and clinicians suggested an online class as an effective alternative to attending the class face-to-face, which could eliminate many barriers to attendance, such as travel distance, transportation links, parking difficulty and cost. Conclusion: Preoperative rehabilitation is valued by both patients and clinicians. Patient-reported outcomes appear similar to conventional post-operative rehabilitation. Further research is needed to determine the efficacy of preoperative rehabilitation in LD patients and to inform clinical practice guidelines.