Background
Several rehabilitation programmes are available for individuals after lumbar disc surgery.

Objectives
To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.

First, we clustered treatments according to the start of treatment.
1. Active rehabilitation that starts immediately postsurgery.
2. Active rehabilitation that starts four to six weeks postsurgery.
3. Active rehabilitation that starts longer than 12 months postsurgery.

For every cluster, the following comparisons were investigated.
A. Active rehabilitation versus no treatment, placebo or waiting list control.
B. Active rehabilitation versus other kinds of active rehabilitation.
C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone.

Search methods
We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013.

Selection criteria
We included only randomised controlled trials (RCTs).

Data collection and analysis
Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence.

Main results
In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76;  95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15).

Authors' conclusions
Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.

Rehabilitation after lumbar disc surgery

Evidence-informed management of chronic low back pain with lumbar extensor strengthening exercises.

Education in the management of low back pain: literature review and recall of key recommendations for practice.

Musculoskeletal disorders are the most common cause of disability in many industrial countries. Recurrent and chronic pain accounts for a substantial portion of workers' absenteeism. Neck pain seems to be more prominent in the general population than previously known. The object of this review is to determine the effectiveness of workplace interventions (WIs) in adult workers with neck pain.

/pdf/workplace-interventions-for-neck-pain-in-workers-1zr63lar2f.pdf

Workplace interventions for neck pain in workers

Study Design.: Cochrane systematic review of randomized controlled trials. Objective.: To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery. Summary of Background Data.: Several rehabilitation programs are available for individuals after lumbar disc surgery, however, little is known about the efficacy of these treatments. Methods.: Search strategies were performed on CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL, and PsycINFO up to May 2007. All randomized controlled trials without language limitations were included. Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence. Results.: Fourteen studies were included, 7 of which had a low risk of bias. Most programs were only assessed in 1 study. Statistical pooling was only completed for 3 comparisons in which exercises started 4 to 6 weeks postsurgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises. We found low quality evidence (3randomized controlled trials [RCTs], N = 122) that exercises are more effective than no treatment for pain atshort-term follow-up (weighted mean difference [WMD]:-11.13; 95% CI: -18.44 to -3.82) and moderate evidence (2 RCTs, N = 102) that exercises are more effective for functional status on short-term follow-up (WMD: -6.50; 95% CI: -9.26 to -3.74). None of the studies reported that exercises increased the reoperation rate. We also found low quality evidence (2 RCTs, N = 103) that high intensity exercises are slightly more effective than low intensity exercise programs for pain in the short-term (WMD: -10.67; 95% CI: -17.04 to -4.30) and moderate evidence (2 RCTs, N = 103) that they are more effective for functional status in the short-term (standardized mean difference [SMD] -0.77; 95% CI: -1.17 to -0.36). Finally, we found low quality evidence (3 RCTs, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD: -1.12; 95% CI: -2.77-0.53) or functional status (3 RCT, N = 95; SMD -1.17; 95% CI: -2.63-0.28). Conclusion.: Exercise programs starting 4 to 6 weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery. © 2009 Lippincott Williams & Wilkins, Inc.

Rehabilitation after lumbar disc surgery: an update Cochrane review.

Low back pain remains a costly quality-of-life-related health problem Microdiscectomy is often the surgical procedure of choice for a symptomatic, single-level, lumbar disc herniation in younger and middle-aged adults The question of whether a post-microdiscectomy exercise program enhances function, quality of life, and disability status has not been systematically explored Thus, the overall purpose of this study is to assess immediate and long-term outcomes of an exercise program, developed at University of Southern California (USC), targeting the trunk and lower extremities (USC Spine Exercise Program) for persons who have undergone a single-level microdiscectomy for the first time One hundred individuals between the ages of 18 and 60 who consent to undergo lumbar microdiscectomy will be recruited to participate in this study Subjects will be randomly assigned to one of two groups: 1) one session of back care education, or 2) a back care education session followed by the 12-week USC Spine Exercise Program The outcome examiners (evaluators), as well as the data managers, will be blinded to group allocation Education will consist of a one-hour "one-on-one" session with the intervention therapist, guided by an educational booklet specifically designed for post-microdiscectomy care This session will occur four to six weeks after surgery The USC Spine Exercise Program consists of two parts: back extensor strength and endurance, and mat and upright therapeutic exercises This exercise program is goal-oriented, performance-based, and periodized It will begin two to three days after the education session, and will occur three times a week for 12 weeks Primary outcome measures include the Oswestry Disability Questionnaire, Roland-Morris Disability Questionnaire, SF-36® quality of life assessment, Subjective Quality of Life Scale, 50-foot Walk, Repeated Sit-to-Stand, and a modified Sorensen test The outcome measures in the study will be assessed before and after the 12-week post-surgical intervention program Long-term follow up assessments will occur every six months beginning one year after surgery and ending five years after surgery Immediate and long-term effects will be assessed using repeated measures multivariate analysis of variance (MANOVA) If significant interactions are found, one-way ANOVAs will be performed followed by post-hoc testing to determine statistically significant pairwise comparisons We have presented the rationale and design for a randomized controlled trial evaluating the effectiveness of a treatment regimen for people who have undergone a single-level lumbar microdiscectomy

/pdf/the-immediate-and-long-term-effects-of-exercise-and-patient-3rmzm5w6l1.pdf

The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol.

Sean P. Flanagan

Papers

The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol.

Chapter 2 – Biomechanics

Chapter 2 – Biomechanics