Is there a rational basis for post-surgical lifting restrictions? 1. Current understanding

Abstract

IntroductionAfter surgery it is a common practice to prescribe lifting restrictions. These seem to be based on a premise that the spine is weaker and thus subject to re-injury when there has been some disruption of the functional spinal motion unit (FSU) due to surgery. Re-injury is not, however, often reported in the literature. More often a failure of fusion is reported [3, 6, 12, 23, 27,72,79].Recurrent low back pain (LBP) or other impairments may exist after back surgery in up to 50% of operated patients [61]. Robert et al. [71] studied the outcome after operation for lumbar herniated nucleus pulposus (HNP). The median duration of postoperative work incapacity was 3.5 months. Seventy-eight percent of the patients resumed full-time work in their previous job, and 75% were pain free. Predictive factors for a good outcome were a preoperative work incapacity of less than 4 weeks and, for men, no daily lifting of heavy weights.Although most surgeons employ some kind of postoperative lifting restrictions, there is not much scientific literature upon which to base those limitations. If the empirical basis for limitations were correct, one would expect a consensus on the limitations (i.e., there would be a tendency for physicians to agree on the correct restrictions).Lifting restrictions are not a trivial issue. A restriction may prevent return to work if the employer is unable, or Abstract Lifting restrictions postoperatively are quite common, but there appears to be little scientific basis for them. Lifting restrictions are inhibitory in terms of return to work and may be a factor in chronicity. The mean functional spinal motion unit stiffness changes with in vitro or computer-simulated discectomies, facetectomies and laminectomies were reviewed from the literature. We modified the NIOSH lifting equation to include another multiplier related to stiffness change post surgery. The new recommended lifts were computed for different lifting conditions seen in industry. The reduction of rotational stiffness ranged from 21% to 41% for a discectomy, 1% to 59% for a facetectomy and 4% to 16% for a partial laminectomy. The recommended lifts based on our modified equation were adjusted accordingly. There is no rational basis for current lifting restrictions. The risk to the spine is a function of many other variables as well as weight (i.e., distance of weight from body). The adjusted NIOSH guidelines provide a reasonable way to estimate weight restrictions and accommodations such as lifting aids. Such restrictions should be as liberal as possible so as to facilitate, not prevent, return to work. Patients need more advice regarding lifting activities and clinicians should be more knowledgeable about the working conditions and constraints of a given workplace to effectively match the solution to the patient's condition.Key words Lifting · Surgery · Return to work · Low back pain · NIOSH ORIGINAL ARTICLE Eur Spine J (1999) 8 : 170-178

National audit of post-operative management in spinal surgery

“…Previous surveys highlighted variations with respect to recommendations regarding return to work ranging from 1–16 weeks [ 7 , 20 ]. Similarly, a study by Magnusson et al [ 21 ] into restrictions on lifting revealed obvious differences in recommendations. Magnusson et al .…”

“…Magnusson et al . [ 21 ] were unable to identify any evidence in the literature to support such restrictions, even when mechanical factors were considered [ 22 ]. Our paper now adds evidence of a notable discordance between post-operative restrictions on sitting and recommendations about return to sedentary work or driving.…”

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression

“…for sitting, driving, or sedentary work. Magnusson et al [42] found similar inconsistency and lack of scientific rationale in advice about lifting, with recommendations about work demonstrating even greater variability [33,40]. Lack of advice, or inconsistent and contradictory advice, makes patients uncertain what they should or should not do postoperatively, which is likely to increase anxiety and inhibit their rehabilitation.…”

Evaluation of the Impact of the Revised National Institute for Occupational Safety and Health Lifting Equation

“…In addition to the suggested additions/revisions to the RNLE by the aforementioned studies (Hidalgo et al, 1997; Jager & Luttmann, 1999; Stambough et al, 1995), Magnusson et al suggested adding the factor of “stiffness change” as yet another multiplier. The recommendation was to be added to accommodate “post-surgery workers” who typically have restricted lifting capabilities (Magnusson, Pope, Wilder, Szpalski, & Spratt, 1999). The rationale for this addition was described in a subsequent paper (Pope, Magnusson, Wilder, Goel, & Spratt, 1999).…”

“…The recommendation was to be added to accommodate “post-surgery workers” who typically have restricted lifting capabilities (Magnusson, Pope, Wilder, Szpalski, & Spratt, 1999). The rationale for this addition was described in a subsequent paper (Pope, Magnusson, Wilder, Goel, & Spratt, 1999). To our knowledge, all the suggested revisions to the RNLE model have not been validated.…”