A descriptive study of the utilization of physical therapy for postoperative rehabilitation in patients undergoing surgery for lumbar radiculopathy

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1 DOI /s ORIGINAL ARTICLE A descriptive study of the utilization of physical therapy for postoperative rehabilitation in patients undergoing surgery for lumbar radiculopathy Adriaan Louw 1,2 Emilio J. Puentedura 1,3 Ina Diener 2 Received: 13 June 2015 / Revised: 7 February 2016 / Accepted: 7 February 2016 Springer-Verlag Berlin Heidelberg 2016 Abstract Purpose To determine the referral patterns, utilization and indications for postoperative physical therapy (PT) for lumbar radiculopathy. At least 50 % of patients following lumbar surgery (LS) for radiculopathy are referred for PT to address postoperative pain and disability. Very little is known regarding factors following LS that predict referral to PT, patient perceptions, satisfaction of postoperative PT and predictors of success for PT following LS for radiculopathy. Methods Sixty-five patients who underwent LS for radiculopathy completed outcome measures on pain and disability prior to, and 1, 3, 6 and 12 months after LS. They also completed a questionnaire regarding postoperative PT at the 12-month follow-up. Results The majority of patients (59.32 %) attended PT after LS for an average of 14 visits and rated PT favorably. Forty-five percent of the patients who did not attend PT after LS were of the opinion that they would have benefitted from PT after LS, and 62.5 % of these patients reported the surgeon not discussing postoperative PT after LS. Patients with longer duration of symptoms prior to surgery, with greater leg pain scores 1 month after surgery, and who did not feel as well prepared for surgery at the & Emilio J. Puentedura louie.puentedura@unlv.edu International Spine Pain Institute and Neuro Orthopaedic Institute, Story City, IA, USA Department of Physiotherapy, Stellenbosch University, Stellenbosch, South Africa Department of Physical Therapy, School of Allied Health Sciences, University of Nevada Las Vegas, 4505 Maryland Parkway, Box , Las Vegas, NV , USA 1 year follow-up were more likely to receive PT, but this did not result in significantly better outcomes on any measure at any follow-up period and did not predict attendance in PT after LS. Conclusion There is a need to determine if a subgroup of patients following LS exists who will respond favorably to postoperative PT. Keywords Postoperative pain Physical therapy specialty Spine Laminectomy Radiculopathy Introduction Current outcome data for lumbar surgery (LS) for radiculopathy indicate approximately one in four patients will experience postoperative pain, loss of movement and disability [1, 2]. With persistent pain and disability, physical therapy (PT) is often advocated to help decrease disability, pain and limited movement [1, 3 5]. To date, various randomized controlled trials and systematic reviews have examined the efficacy of postoperative PT for LS [5 8]. A review of high-quality randomized controlled trials and systematic reviews finds evidence to support the utilization of PT after surgery [5, 9, 10], as well as evidence showing little to no effect [6 8]. For example, in an extensive Cochrane review of 14 randomized controlled trials, Ostelo et al. reported that exercise programs starting 4 6 weeks post-lumbar surgery led to a faster decrease in pain and disability when compared with no treatment [5]. Dolan, studying the benefit of adding a 4-week postoperative PT exercise routine to micro-discectomies, showed additional benefit with regard to pain and function compared to patients receiving no PT after LS [3]. However, despite this evidence in support of

2 postoperative rehabilitation after LS, various issues remain unanswered including dosage, frequency, duration, etc. [1, 5]. In contrast, studies have also shown little to no effect for PT after LS [2, 6, 7, 11]. For example, an extensive threephase postoperative PT program compared to usual care consisting of no formal physical therapy after LS showed no difference at the 1-year follow-up [7]. In a recent multicenter randomized controlled trial of 338 patients receiving various combinations of postoperative PT, and educational booklet or usual care, the 1-year follow-up showed no advantage to receiving postoperative rehabilitation [6]. Studies have even explored various styles of postoperative rehabilitation. In a 1-year outcome study after LS, a comprehensive PT-driven behavioral graded program showed no difference compared to usual postoperative PT with regard to functional status, pain rating, pain catastrophization, fear of movement, range of motion, general health, social functioning or return to work at both 6-month and 1-year follow-up [2, 11]. The conflicting evidence for rehabilitation following LS could be explained by the proposition that some patients will actually need postoperative PT and demonstrate benefit, whereas other patients may not need it and, therefore, demonstrate little to no benefit. Consequently, understanding which patients will need postoperative PT following LS is an integral part of appropriate referral. To the best of our knowledge, no studies have investigated which factors (pre- and postoperative) may predict referral to and success with postoperative PT. Therefore, the purpose of this secondary analysis was twofold. First, we examined which factors predicted referral to PT following LS for lumbar radiculopathy in a cohort of 65 patients. Second, we assessed the extent to which those factors might predict perceived success by those patients. Methods We performed a secondary analysis of data from a randomized controlled clinical trial comparing preoperative education interventions for patients scheduled for LS for lumbar radiculopathy [12]. In that study, 92 patients who were scheduled to undergo LS were screened, and following exclusions outlined in the study, a sample of 67 patients was randomly assigned to receive preoperative usual care education delivered by the surgeon and his staff (usual care group) or a combination of usual care plus one session of preoperative pain neuroscience education delivered by a physical therapist (experimental group). The primary outcomes of the original study were pain (back and leg) and disability. Sample size calculation for the original study was estimated from preliminary data taken from 15 subjects [12], and it was determined that between 56 and 99 patients would be required to see an interaction effect for a 2 (group) 9 5 (time) mixed factorial analysis of variance [12]. Participants Patients were recruited from seven spinal surgery centers in six different states within the USA. Patients with lumbar radiculopathy, who were scheduled for LS, were invited to participate. Inclusion criteria were: (1) scheduled for LS for radiculopathy; (2) willingness to comply with the predetermined follow-ups; and (3) willingness to complete postoperative questionnaires at designated time intervals. Exclusion criteria were: (1) age less than 18 years or more than 65 years; (2) not being proficient in reading or comprehending the English language; (3) scheduled for LS involving instrumentation (e.g., spinal fusion, arthroplasty); (4) participation in a formal back school or multidisciplinary pain management program; (5) undergoing LS for a condition other than lumbar radiculopathy; (6) presence of chronic pain-related conditions (e.g., fibromyalgia, chronic fatigue syndrome); or (7) symptoms of cord compression. All patients provided informed consent prior to their enrollment in the study. The details of the trial interventions are reported elsewhere [12]. Outcomes The outcome measure time frames were chosen based on past postoperative LS studies [2, 6, 11]. Prior to pain neuroscience education and after completion of the consent and demographic intake forms, patients were asked to complete self-report surveys related to pain, function, knowledge of pain and beliefs regarding surgical outcome. Low back pain and leg pain were measured with the use of a numeric pain rating scale (NPRS), as has been used in various randomized controlled trials for pain neuroscience education and spinal pain [13, 14]. A change of 2.1 has been proposed as the minimal detectable change (MDC) [14]. The Oswestry Disability Index (ODI) [15], a 10-item questionnaire, was used to assess different aspects of physical function. The ODI has been shown to be a valid and reliable measure of disability related to low back pain [15]. A change of five points (10 %) has been proposed as the minimal clinically important difference (MCID) [16]. All intake forms were completed by the patients with no input from therapists, physicians, physician staff or researchers, placed in a pre-paid sealed envelope and mailed to an independent research assistant for data entry. Data were collected a further four times at 1, 3, 6 and 12 months after surgery. Data packets were sent out by an independent research assistant and returned to the same

3 assistant. Patients who did not return their assigned postoperative packets in the allotted time frames were sent reminders via mail (postcard), or phone calls. Patients were offered a US $20 gift card at each interval for completion of the packets (preoperatively, 1, 3, 6 and 12 months). Postoperative physical therapy At the 12-month follow-up, patients were asked to complete a questionnaire regarding postoperative PT. The questionnaire asked them to indicate whether or not they had received PT for treatment of their back and/or leg pain following their surgery, and depending on their answer (yes/no) posed a series of follow-up questions about that therapy. If they answered in the affirmative, they were asked how they came to attend; how many visits in total they had received; did they think the PT had been helpful; which interventions had been included in their therapy treatment; and of all the interventions provided, which did they think had helped them the most. If they answered in the negative, they were asked to consider why they had not received it; whether they thought it would have benefitted them; whether their surgeon had ever discussed it; and whether they thought their surgeon was in favor or against PT after lumbar surgery. The questionnaire is provided in Appendix. Statistical analysis Frequencies were calculated for patients attending PT following LS, and for each answer to the questionnaire; however, no inferential statistics were performed as we had no a priori hypotheses. To identify factors predictive of PT utilization, we conducted univariate analyses to determine if there were any significant associations between baseline data (potential predictor variables) and whether patients received postoperative PT. Statistical significance was set at p = Results Patients Of the 67 patients enrolled in the trial, 2 did not undergo LS and 4 were lost to follow-up (3 from the experimental group and 1 from the usual care group) leaving 61 patients at each follow-up point. These 61 patients were recruited from spine surgical centers in the following cities and states: Des Moines, IA (20); Kansas City and St. Joseph, MO (21); Spartanburg, SC (8); Boise, ID (5); Madison, WI (4) and Las Vegas, NV (3). Table 1 provides the demographic and baseline data on the 65 patients enrolled in the original study. Physical therapy Fifty-nine of 61 questionnaires (96.7 %) regarding postoperative PT at 1 year following LS were returned for data analysis. Two patients did not complete and return the questionnaires despite multiple requests. Thirty-five patients (59.32 %) attended PT following LS. The majority of patients attending PT after LS were referred by their surgeon (65.71 %), followed by specifically asking the surgeon to be referred to PT (25.71 %) and 8.58 % attended PT by self-referral (Fig. 1). Twenty-four patients (40.68 %) did not attend PT following LS. Fourteen of the 24 patients (58.33 %) reported that their surgeon had simply not sent them/not recommended it. The factors associated with not attending PT after LS can be seen in Fig. 2. Eleven of the 24 patients (45.83 %) who did not receive PT after LS believed that it would have helped their recovery. Additionally, 15 of those 24 patients (62.5 %) reported the surgeon never discussed it with them. In response to whether their surgeon gave them the impression that they did not believe in postoperative PT [strongly disagree (0) strongly agree (10)], patients scored an Table 1 Demographic information and baseline data on the 65 patients enrolled in the original RCT, of which 61 were available for this study Characteristic EG (n = 31) CG (n = 34) p value Age (years) (mean) Gender (female) 17 (53 %) 19 (54 %) Duration of symptoms (days) Low back pain (NPRS 0 10) (mean) Leg pain (NPRS 0 10) (mean) Pain catastrophization scale (0 52) Fear avoidance-work subscale (0 42) Fear avoidance-physical activity (0 24) Oswestry Disability Index (0 100) EG experimental group, CG control group, NPRS numeric pain rating scale

4 70.00% 60.00% 50.00% 40.00% 30.00% 65.71% 25.71% who endured symptoms longer prior to LS (p = 0.025), who experienced more leg pain at 1 month after LS (p = 0.019) and who rated lower agreement 1 year after surgery that the preoperative education had prepared them well for LS (p = 0.026) were more likely to attend PT. None of these three factors were found to have any predictive value for perceived success following LS % 10.00% 8.58% Discussion 0.00% Surgeon referred Asked for referral Self referred 25.71% 8.58% 65.71% average reply of 2.54 indicating disagreement with the proposition that surgeons opposed postoperative PT. The patients who attended PT after LS completed an average of visits. They rated the helpfulness of postoperative PT on a 10-point scale [strongly disagree (0) strongly agree (8)] as an average of 6.67 indicating agreement with the proposition that postoperative PT was helpful. The most common treatment intervention received by patients was therapeutic exercise, with 33 out of 35 patients (94.29 %) reporting that they had participated in some. Spinal stabilization was reported by 22 out of 35 patients (62.86 %) and passive stretches by 21/35 patients (60.00 %). All other PT treatment interventions received can be found in Table 2. Rationale for postoperative physical therapy after lumbar surgery Surgeon referred Asked for referral Self referred Fig. 1 Reasons patients attended physical therapy after lumbar surgery All of the preoperative intake data, as well as postoperative data at 1, 3, 6 and 12 months were analyzed to determine if a statistical significance (p = 0.05) existed between patients who received PT after LS versus those who did not (Table 3). Multiple comparisons were made, resulting in only three factors being statistically different between patients who received PT and those who did not. Patients The results from this study provide some interesting insight into the use of PT for postoperative rehabilitation following LS. Almost 60 % of the patients in this study received PT after LS, which concurs with previous survey studies on postoperative rehabilitation after LS [4, 17]. The overall experience of patients who attended PT was favorable and the treatments received appear in line with published studies utilizing the same treatment approaches [3, 6, 7, 12, 18]. Various randomized controlled trials and systematic reviews have postulated that patients who report persistent pain and disability after LS are sent to PT for rehabilitation [1, 3 6]. The results from this study only partially support that proposition. Although there were no significant differences between back pain and disability scores at any follow-up point in patients who received PT when compared with those who did not, patients with greater leg pain at 1 month did attend PT. We can only surmise that surgeons may have more readily referred patients to PT, or patients themselves may have asked for a referral or referred themselves to PT if they felt that they had persistent and higher leg pain scores. Patients who had longer duration of symptoms prior to LS were also more likely to attend PT. This may suggest that surgeons or the patients themselves may have felt that they would require more structured rehabilitation following LS because of the longstanding nature of their symptoms. However, our questionnaire could not capture these data and we can therefore only consider these as possible reasons. An interesting finding was that patients who reported they felt less prepared for surgery at the 1-year follow-up were more likely to attend PT. We asked patients to rate their level of agreement with the statement The preoperative education I received prepared me well for the surgery on a 10-point Likert scale, with 0 indicating strong disagreement and 10 indicating strong agreement. Although not significantly different until the 1-year followup, patients who attended PT reported lower mean scores in agreement with the statement at each time point. We can only speculate as to why patients who felt less prepared for their surgery might be more likely to attend PT after LS.

5 Fig. 2 Reasons patients did not attend physical therapy after lumbar surgery 70.00% 60.00% 58.33% 50.00% 40.00% 30.00% 20.00% 10.00% 16.67% 12.50% 8.33% 4.17% 0.00% Surgeon did not recommend Did not need it Not sure why not Insurance/money Other 8.33% 4.17% 12.50% 16.67% 58.33% Surgeon did not recommend Did not need it Not sure why not Insurance/money Other Table 2 Treatment interventions reportedly received by the patients who indicated they participated in postoperative physical therapy following their lumbar surgery Treatments Number of times chosen Percentage Exercise Spinal stabilization Stretches Electrical stimulation Home exercise program Cold/cryotherapy Education Massage Hot moist pack Neural mobilization Spinal manipulation 7 20 Transcutaneous electrical neuromuscular stimulation (TENS) 7 20 One possible explanation is that, in feeling less prepared, they may have communicated this to their surgeon and subsequently organized referral to PT. Findings from this study should be viewed in light of the current evidence for and against postoperative PT for LS [1, 5]. More precisely, there is a call for studies to determine the factors that may be predictors of referral for, and success with PT after LS. The call for such studies parallels the recent classification-based research of the various PT treatments for non-surgical low back pain [19, 20]. By analyzing the presence of predictive factors in patients with low back pain, physical therapists are able to match patients to various treatments associated with an increased likelihood of success such as spinal manipulation [19], traction [20], spinal stabilization exercises [21] and directional preference [22]. With respect to LS, most postoperative PT studies have focused on therapeutic exercise [3, 5, 7, 18]. Following a classification-based approach, it could be argued that a sub-group of patients exists which

6 Table 3 Mean values, standard deviation (±SD) and statistical differences (p values) for the preoperative and postoperative variables between patients receiving physical therapy (first value and in bold) after lumbar surgery compared to those not receiving therapy (second value, not bolded) Measurement Preoperative 1 Month 3 Months 6 Months 12 Months Age (years) ± (p = 0.970) Duration of symptoms (days) ± (p = 0.025)* LBP (0 10) ± ± ± ± ± 3.13 (p = 0.235) (p = 0.311) (p = 0.405) (p = 0.315) (p = 0.335) Leg pain (0 10) ± ± ± ± ± 2.84 (p = 0.601) (p = 0.019)* (p = 0.788) (p = 0.62) (p = 0.741) Function (ODI 0 50) ± ± ± ± ± (p = 0.479) (p = 0.065) (p = 0.274) (p = 0.074) (p = 0.740) Pain knowledge (0 19) ± ± ± ± ± 2.06 (p = 0.793) (p = 0.557) (p = 0.413) (p = 0.967) (p = 0.834) I feel prepared and ready to have back surgery (0 10) ± 1.87 (p = 0.423) I am afraid of the upcoming back surgery (0 10) ± 2.73 (p = 0.947) I know what to expect after the back surgery (0 10) ± 2.67 (p = 0.158) Back pain after the surgery is to be expected (0 10) ± 3.08 (p = 0.868) Leg pain after the surgery is to be expected (0 10) ± 3.00 (p = 0.183) I can control the amount of pain I may experience after the surgery (0 10) ± 2.15 (p = 0.268) The back surgery will fix my pain (0 10) ± 2.34 (p = 0.801) I am glad I underwent surgery for my leg pain (0 10) ± ± ± ± 3.31 (p = 0.891) (p = 0.924) (p = 0.731) (p = 0.535) I was fully prepared (physically, emotionally, psychologically) for the surgery (0 10) ± ± ± ± 2.86 (p = 0.113) (p = 0.269) (p = 0.729) (p = 0.349)

7 Table 3 continued Measurement Preoperative 1 Month 3 Months 6 Months 12 Months The preoperative education I received prepared me well for the surgery (0 10) ± 2.47 (p = 0.165) ± 1.94 (p = 0.122) ± 2.43 (p = 0.721) ± 2.21 (p = 0.026)* Knowing what I know now, I would do this again given the same choices (0 10) 8.6 ± 2.89 (p = 0.739) The surgery met my expectations (0 10) ± 2.83 (p = 0.675) ± 2.67 (p = 0.441) ± 3.84 (p = 0.620) ± 2.49 (p = 0.182) ± 3.60 (p = 0.903) ± 2.90 (p = 0.212) 8.3 ± 2.65 (p = 0.077) * indicates statistical significance (p \ 0.05) will respond favorably to a PT exercise approach after LS. If we continue with research trials where all patients receive PT after LS, including ones who may not need it, then the efficacy of postoperative PT is likely to be diminished and we will continue to find no significant benefit for it. This appears to be the most likely reason why postoperative PT has shown a limited efficacy when viewing randomized controlled trials and systematic reviews [5]. Before engaging in future studies to determine the efficacy of various postoperative PT approaches, the results from this study demand further investigation for factors that may be predictive of success with various PT treatments after LS. Findings from this study also highlighted issues related to surgeon-led referral to PT following LS. Almost half of the patients who did not receive PT after LS were of the opinion that it could have benefitted them, and more than 60 % reported no discussion about PT after LS by their surgeon. Additionally, one in three patients who did attend therapy asked to be referred or referred themselves to PT after LS. The various reasons for the limited referral or discussion of PT after LS remain to be clarified [4, 17]. One argument may be that surgeons do not view PT after LS as important and thus provide a rather negative view of PT. This study, however, reported patients in general not getting that perception, which concurs with a survey studying US spine surgeon referral patterns [17]. It could be argued that in view of the confounding evidence for and against postoperative PT for LS [1, 5], surgeons may not have enough evidence to support referring patients to PT after LS. The inability to identify which perioperative factors are predictive of PT referral, let alone success, as seen in the results of this study can be added to this dilemma. Spinal surgery is mired in various issues related to decision-making differences among surgeons [23, 24]. The findings of this study may further fuel the need for additional research to identify patients who may/may not respond to PT after LS, including the specifics of the PT treatment plan. Upon development of such programs, the information should be disseminated to surgeons to help in the decision-making process for PT after LS. Study limitations This study was a retrospective analysis of data from a previous clinical trial which used patient reports and thoughts about their attendance (or not) in postoperative PT. We did not record the surgeons reasons for referring or not referring to PT and relied on patient reports which could likely have led to type II errors in our findings. Similarly, we relied upon reports from patients about the PT interventions they received, which may not equate to those actually received. A fidelity check of the PT notes was not possible for this study proposal, and this has to be acknowledged as a further study limitation. The sample size was relatively small (n = 59) and this left us underpowered in our statistical analyses. Future studies using larger samples are recommended. The questionnaire used was, by necessity, a limited one, as we did not wish to overburden patients in the original trial with paperwork. Another limitation of the present study would be that surgeons reports and thoughts about postoperative physical therapy were not collected in the primary study. Conclusions Postoperative PT following LS occurs in about 60 % of cases, but the reasons for receiving therapy remain unclear. Patients with longer duration of symptoms prior to surgery, and with greater leg pain scores 1 month after surgery, were more likely to receive PT, but this did not result in significantly better outcomes on any measure at any follow-up period. There is a need to determine if a subgroup of patients following LS exists who will respond favorably

8 to postoperative PT and then describe the specific content of such a postoperative PT program. Conflict of interest interest. None of the authors has any potential conflict of Compliance with ethical standards The protocol for this study was reviewed and approved by Stellenbosch University Board of Institutional Review/Ethics. The manuscript submitted does not contain information about medical device(s). The authors affirm that they have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. Appendix: Physical Therapy Survey following Back Surgery ** The answers are confidential and not shared with your surgeon/case manager (if applicable) Since having your back surgery, did you attend any physical therapy for treatment of your back or leg? Yes If yes, please complete the questions in the yes column No If no, please complete the questions in the no column YES have received physical therapy 1. How did you end up in physical therapy? Referred myself Asked the surgeon to refer me Referred by the surgeon Other: (please fill in) 2. How many physical therapy visits in total did you receive after back surgery up to now? 3. Do you agree or disagree with the statement: Physical therapy was very helpful in my recovery after back surgery. Please mark on the scale below NO have not received physical therapy 1. Why did you not receive physical therapy? Did not need it Surgeon did not send me/recommended it Not sure why not Other: (please fill in) 2. Do you think you would have benefitted from physical therapy after back surgery? Yes No 3. Did your surgeon ever discuss any therapy after back surgery? Yes No More questions on the back Almost done 4. Do you agree or disagree with this statement: My surgeon gave me the impression he/she did not like therapy after back surgery. Please mark on the scale below DONE Thank You

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