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Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis

Abstract

Purpose

To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis.

Methods

Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE.

Results

In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: −0.41 [−0.71; −0.10] and −0.36 [−0.65; −0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (−0.31 [−0.49; −0.13] and −0.64 [−1.11; −0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies).

Conclusion

There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

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Acknowledgements

The authors wish to thank Thomas Vandendriessche, Kristel Paque and Krizia Tuand, the biomedical reference librarians of the KU Leuven Libraries, 2Bergen Learning Centre Désiré Collen (Leuven, Belgium), for their help in conducting the systematic literature search.

Funding

This work was supported by the Research Foundation—Flanders (FWO, grant 1181521N) and Competence Centre Physiotherapy UZ/KU Leuven.

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All authors contributed to the study conception and design. The articles screening and selection was performed by LB and TT. Studies' quality assessment and data extraction was performed by LB, TT and CA. Analysis and interpretation of results was performed by LB, LJ and TWS. The first draft of the manuscript was written by LB and all authors revised it critically for important intellectual content. All authors read and approved the final manuscript.

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Correspondence to Liedewij Bogaert.

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Bogaert, L., Thys, T., Depreitere, B. et al. Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis. Eur Spine J 31, 1525–1545 (2022). https://doi.org/10.1007/s00586-022-07158-2

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Keywords

  • Rehabilitation
  • Spinal fusion
  • Exercise
  • Physical therapy
  • Cognitive behavioral therapy
  • Return to work