Rehabilitation after lumbar spine surgery in adults: a systematic review with meta-analysis

Abstract

Background The role of rehabilitation after surgery in patients with low back pain is well recognized. The aim of this systematic review is to summarize and update the existing evidence according to the type of clinical condition and rehabilitation approach. Methods This systematic review included RCTs on the effectiveness of rehabilitation after surgery for lumbar disc herniation, spinal stenosis, and spondylolisthesis. We searched the literature for randomized controlled trials indexed in MEDLINE, Embase, CINHAL, CENTRAL, Scopus, PEDro, and Web of Science databases, up to April 15, 2023. We used Cochrane Risk of Bias 2.0 tool to assess each study. We conducted a quantitative synthesis when population, intervention, control, and outcome were sufficiently homogeneous; otherwise, we conducted a qualitative analysis. Results Forty-five studies (3.036 subjects) were included and analyzed according to the population considered: lumbar stenosis (1 trial), spondylolisthesis (3 trials), and disc herniation (41 trials). Regarding lumbar stenosis, a supervised active exercise program appears to improve outcomes related to pain, disability, and quality of life both in the short- and mid-term (1 study, n = 60). Concerning spondylolisthesis, kinesiophobia is reduced in the home exercises group compared to usual care, at 3-months follow-up (3 studies, n = 98). For disk herniation, supervised exercises are better than non-supervised exercises to reduce pain (MD -1.14; 95% CIs -1.65, -0.62; 5 trials, n = 250) and disability (SMD -0.70; 95% CIs -1.14, -0.26; 4 trials, n = 175). Supervised exercises are better than advice in reducing pain (SMD -0.91; 95% CIs -1.61, -0.21; 5 trials, n = 341) and disability (SMD -0.80; 95% CIs -1.59, -0.01; 4 trials, n = 261), in the short-term. Supervised exercises are equal to no treatment in reducing pain and disability, at 3 and 6 months after intervention (2 trials, n = 166). These results are supported by a very low to low quality of evidence. Conclusions Our research suggests that supervised exercise may be effective in improving patient’s pain and disability after lumbar surgery, but RCTs regarding lumbar spinal stenosis and lumbar spondylolisthesis are still scarce, with significant heterogeneity of proposed interventions.

Effectiveness of postsurgical rehabilitation following lumbar disc herniation surgery: A systematic review

“…Our systematic review augments their conclusions based on high certainty evidence that supervised exercise (i.e., Pilates exercise) improved function, and remote exercise was no different to education or usual post-surgical care. Regarding exercise types, the sensitivity analysis in our review supports findings of Ostelo et al (2008) , Oosterhuis et al (2014) and Manni et al (2023) that supervised exercise was superior to non-supervised exercise. It is important to note that these findings are related to high risk of bias studies and very low certainty evidence overall.…”

“…Differences in the overall results between our review and the previous reviews may be due to several factors ( Oosterhuis et al, 2014 ; Ostelo et al, 2008 ; Rushton et al, 2011 ; Snowdon and Peiris, 2016 ; Manni et al, 2023 ). First, we did not use broad categories of treatment such as physiotherapy because such a strategy prevents the assessment of the effectiveness and safety of specific interventions.…”

“…There are five systematic reviews identified in evaluating rehabilitation interventions after lumbar surgery for LDH published between 2008 and 2023 ( Oosterhuis et al, 2014 ; Ostelo et al, 2008 ; Rushton et al, 2011 ; Snowdon and Peiris, 2016 ; Manni et al, 2023 ). Relying on very low quality evidence, Ostelo et al (2008) and Oosterhuis et al (2014) reported that exercise programs beginning four to six weeks post-surgery result in a faster decrease in short-term pain and disability compared to no treatment.…”

“…Relying on very low quality evidence, Ostelo et al (2008) and Oosterhuis et al (2014) reported that exercise programs beginning four to six weeks post-surgery result in a faster decrease in short-term pain and disability compared to no treatment. Furthermore, the newly published systematic review by Manni et al (2023) concluded that: 1) supervised exercises are better than non-supervised exercises to reduce pain and disability; and 2) supervised exercises are better than advice in reducing pain and disability, both based on very low to low certainty evidence (i.e., heterogeneous and low quality RCTs) ( Manni et al, 2023 ). Our systematic review augments their conclusions based on high certainty evidence that supervised exercise (i.e., Pilates exercise) improved function, and remote exercise was no different to education or usual post-surgical care.…”

“…Fifth, our review limited eligible rehabilitation interventions to those provided within three months post-surgery. Lastly, two studies( McGregor et al, 2011 ; Scrimshaw and Maher, 2001 ) included in Ostelo et al (2008) , Oosterhuis et al (2014) and Manni et al (2023) were excluded from this review because participants received fusion for lumbar stenosis.…”