Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation

Oosterhuis, Teddy; Ostelo, Raymond; Dongen, Johanna M. van; Peul, Wilco C.; Boer, Michiel R. de; Bosmans, Judith E.; Vleggeert-Lankamp, Carmen L. A.; Arts, Mark P.; Tulder, Maurits W. van

doi:10.1016/j.jphys.2017.05.016

Cited by 38 publications

(85 citation statements)

References 36 publications

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“…In the UK, where patients live geographically dictates whether they receive rehabilitation, and if they do, the content and number of sessions of rehabilitation is inconsistent [8]. A recent RCT found no benefit (clinical effectiveness or cost-effectiveness) of early referral for physiotherapy following surgery compared to no referral [9]. Postoperative rehabilitation could possibly be harmful for patients if outcomes from the clinical course are better than outcomes of rehabilitation interventions.…”

Section: Rationalementioning

confidence: 99%

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis

et al. 2020

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Purpose To conduct a meta-analysis to describe clinical course of pain and disability in adult patients post-lumbar discectomy (PROSPERO: CRD42015020806). Methods Sensitive topic-based search strategy designed for individual databases was conducted. Patients (> 16 years) following first-time lumbar discectomy for sciatica/radiculopathy with no complications, investigated in inception (point of surgery) prospective cohort studies, were included. Studies including revision surgery or not published in English were excluded. Two reviewers independently searched information sources, assessed eligibility at title/abstract and full-text stages, extracted data, assessed risk of bias (modified QUIPs) and assessed GRADE. Authors were contacted to request raw data where data/variance data were missing. Meta-analyses evaluated outcomes at all available time points using the varianceweighted mean in random-effect meta-analyses. Means and 95% CIs were plotted over time for measurements reported on outcomes of leg pain, back pain and disability. Results A total of 87 studies (n = 31,034) at risk of bias (49 moderate, 38 high) were included. Clinically relevant improvements immediately following surgery (> MCID) for leg pain (0-10, mean before surgery 7.04, 50 studies, n = 14,910 participants) and disability were identified (0-100, mean before surgery 53.33, 48 studies, n = 15,037). Back pain also improved (0-10, mean before surgery 4.72, 53 studies, n = 14,877). Improvement in all outcomes was maintained (to 7 years). Metaregression analyses to assess the relationship between outcome data and a priori potential covariates found preoperative back pain and disability predictive for outcome. Conclusion Moderate-level evidence supports clinically relevant immediate improvement in leg pain and disability following lumbar discectomy with accompanying improvements in back pain.

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Section: Rationalementioning

confidence: 99%

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis

et al. 2020

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“…Early referral to physiotherapy has the potential to reinforce necessary postoperative movement precautions while working on patients’ functional recovery, including mobility, transfers, sitting and lifting exercises. The results of a recent trial, however, challenge these conclusions 8. Oosterhuis et al revealed that early rehabilitation after lumbar disc surgery had no significant effect on clinical outcomes or societal costs compared with no referral 8…”

Section: Discussionmentioning

confidence: 99%

Early comprehensive physiotherapy after lumbar spine surgery (PEDro synthesis)

Machado

Pinheiro

2017

Br J Sports Med

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“…Supervised exercise therapy can be a high-value alternative to surgery and harmful pharmacological treatments, but optimizing value remains vital. There are many situations where intensive supervision for recreational athletes or the general population adds no benefit to a home-based program involving minimal supervision (eg, following an ACL reconstruction, [69][70][71] following lumbar disc surgery, 72,73 post-immobilization of an ankle 74 or distal radius fracture, 75 management of rotator cuff tendinopathy 76 ). For example, a randomized controlled trial of 145 recreational athletes following an ACL reconstruction found no difference in quality of life, range of motion, laxity, and quadriceps or hamstring strength at any time (up to 4 years) between athletes that received 17 sessions of supervised exercise compared to 4 sessions (eg, limb symmetry index scores for peak quadriceps torque at 60 degrees/s were similar between groups: mean difference (MD) 7.0%, 95% CI: −4.6 to 18.7, P = .23, n = 60).…”

Section: Exercise Therapymentioning

confidence: 99%

“…72 In fact, a more recent randomized controlled trial (n = 169) found that exercise therapy commencing within 1 week of discharge was not superior to no treatment for improving pain and disability at any time point following lumbar disc surgery (up to 6 months), and instead, led to higher medical costs. 73 A randomized controlled trial of 33 patients' post-immobilization of a distal radius fracture found that a 6-week structured exercise program plus three sessions of structured advice with a physiotherapist was not superior to advice alone for improving upper limb activity, range of motion, strength, or pain. 75 For patients with rotator cuff tendinopathy, a randomized controlled trial (n = 86) found that usual physiotherapy was not superior to a self-management program involving a single exercise for improving pain and disability, function, and quality of life.…”

Section: Exercise Therapymentioning

confidence: 99%

High‐ and low‐value care in sport and exercise medicine: Areas for consideration

2020

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High‐value care and low‐value care are concepts failing to receive attention in sport and exercise medicine. High‐value care refers to an intervention that provides a benefit or where the probable benefit exceeds the risk of harm. Low‐value care refers to an intervention that provides little‐to‐no benefit or where the risk of harm exceeds the probable benefit. To start the conversation, we apply the concepts of high‐ and low‐value care to the use of imaging, opioids, injections, surgery, and exercise therapy in sport and exercise medicine. We conclude with suggestions to help sport and exercise medicine clinicians replace low‐value care with high‐value care. In summary: (a) Only order imaging if you suspect findings that will positively guide the direction of treatment; (b) To reduce opioid use, ensure an adequate trial of non‐pharmacological and non‐opioid treatments; (c) Only provide injections when an adequate trial of non‐pharmacological treatments has failed, and the short‐term benefits outweigh the risk of long‐term harms; (d) Consider initial non‐surgical management for cases where evidence suggests early surgery is not necessary (eg, anterior cruciate ligament tears); and (e) Promote independence with exercise therapy (instead of extensive supervision) when feasible, acceptable, and evidence suggests it has equivalent outcomes (eg, post‐surgery).

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Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation

Cited by 38 publications

References 36 publications

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis

Early comprehensive physiotherapy after lumbar spine surgery (PEDro synthesis)

High‐ and low‐value care in sport and exercise medicine: Areas for consideration

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