In patients with severe low back pain planned for lumbar fusion surgery

Introduction: Low back pain is a frequently reported symptom and has turned into a global problem. For people with severe chronic low back pain, spinal fusion surgery can be a treatment option. The outcome of fusion surgery is not always successful and some patients report having a low quality of life after surgery. The overall purpose of this thesis was to develop and evaluate a prehabilitation programme for patients scheduled for lumbar fusion surgery. In addition, the aim was to investigate the pre-surgical level of physical activity in this group. Material and methods: In Study I, a person-centred prehabilitation programme was developed in several steps and tested in a single case study design. In Study II, the theoretical framework and the treatment manual for the active intervention were described in detail in the format of a study protocol. In Study Ⅲ the physical activity level of 118 patients planned for surgery due to degenerative disc disease was investigated objectively in a cross-sectional study. An association between factors in the fear-avoidance model and physical activity were investigated. In Study Ⅳ the effect of the prehabilitation programme was evaluated in a randomised controlled trial comparing the active intervention to conventional care. A linear mixed model was used to evaluate the outcome measures at six months after lumbar fusion surgery. Results: The theoretical framework and the treatment manual of the prehabilitation programme were adjusted after the single case study (Study I). The revised study design was published in a study protocol (Study II). Only 17% of the study group fulfilled the WHO recommendations of physical activity for health benefits. The variable “steps per day” was found to be associated with both fear of movement and disability (Study Ⅲ ). No statistically significant differences between groups were seen in the primary outcome disability from baseline to six months (Study IV). Among secondary outcome measures, a statistically-significant interaction effect was seen for EQ-5D index with the largest between-group difference seen one week prior to surgery in favour of the active intervention. Both groups reached the minimal important change for the primary outcome, and many of the secondary outcomes already at 8 weeks follow-up. Conclusion: These findings, indicate that patients planned for lumbar fusion surgery have low physical activity level and are thereby at greater risk of poor health. A prehabilitation programme leads to minimal important changes for the primary outcome, and many of the secondary outcomes already at 8 weeks follow-up

Fear of movement was associated with sedentary behaviour 12 months after lumbar fusion surgery in patients with low back pain and degenerative disc disorder

BACKGROUND: Movement behaviours, such as sedentary behaviour (SB) and moderate to vigorous physical activity (MVPA), are linked with multiple aspects of health and can be influenced by various pain-related psychological factors, such as fear of movement, pain catastrophising and self-efficacy for exercise. However, the relationships between these factors and postoperative SB and MVPA remain unclear in patients undergoing surgery for lumbar degenerative conditions. This study aimed to investigate the association between preoperative pain-related psychological factors and postoperative SB and MVPA in patients with low back pain (LBP) and degenerative disc disorder at 6 and 12 months after lumbar fusion surgery. METHODS: Secondary data were collected from 118 patients (63 women and 55 men; mean age 46 years) who underwent lumbar fusion surgery in a randomised controlled trial. SB and MVPA were measured using the triaxial accelerometer ActiGraph GT3X+. Fear of movement, pain catastrophising and self-efficacy for exercise served as predictors. The association between these factors and the relative time spent in SB and MVPA 6 and 12 months after surgery was analysed via linear regression models, adjusting for potential confounders. RESULTS: Preoperative fear of movement was significantly associated with relative time spent in SB at 6 and 12 months after surgery (β = 0.013, 95% confidence interval = 0.004 to 0.022, p = 0.007). Neither pain catastrophising nor self-efficacy for exercise showed significant associations with relative time spent in SB and MVPA at these time points. CONCLUSIONS: Our study demonstrated that preoperative fear of movement was significantly associated with postoperative SB in patients with LBP and degenerative disc disorder. This finding underscores the potential benefits of preoperative screening for pain-related psychological factors, including fear of movement, preoperatively. Such screenings could aid in identifying patients who might benefit from targeted interventions to promote healthier postoperative movement behaviour and improved health outcomes

A Person-Centred Prehabilitation Program based on Cognitive-Behavioural Physical Therapy for patients scheduled for Lumbar Fusion surgery: A mediation analysis to assess fear of movement (kinesiophobia), self-efficacy, and catastrophizing as mediators of health outcomes.

Objective To investigate whether early changes in fear of movement (kinesiophobia), self-efficacy, and catastrophising were mediators of the relationship between allocation to the pre-habilition intervention and later changes in health outcomes. Methods The original prehabilitation trial (PREPARE, ISRCTN17115599) recruited 118 participants awaiting lumbar fusion surgery, half of whom received a prehabilitation intervention designed based on the modified fear-avoidance model and half of whom received usual care. Mediation analysis was performed to test each mediator separately. Analysis was performed on each outcome of interest separately (Oswestry Disability Index; Patient-Specific function; EQ General health; and Moderate/vigorous physical activity). Mediation analysis was carried out using PROCESS. Beta coefficients and bootstrapped 95% CIs were used to interpret the results. Results None of the potential mediators were found to mediate the relationship between allocation to the intervention and three-month scores on any of the health outcomes tested. Conclusions Screening patients for higher levels of catastrophising and fear-avoidance, and lower levels of self-efficacy, could help ensure only the patients who are most likely to benefit from the intervention are included

Patients with severe low back pain exhibit a low level of physical activity before lumbar fusion surgery: a cross-sectional study

Abstract Background People with severe low back pain are at higher risk of poor health. Patients scheduled for lumbar fusion surgery are assumed to have low levels of physical activity, but few data exist. The aim of the study was firstly to investigate preoperative levels of objectively measured physical activity in patients with severe low back pain waiting for lumbar fusion surgery, and secondly to investigate whether factors in the fear-avoidance model were associated with these levels. Methods We included 118 patients waiting for lumbar fusion surgery (63 women and 55 men; mean age 46 years). Physical activity expressed as steps per day and total time spent in at least moderate-intensity physical activity was assessed with ActiGraph GT3X+ accelerometers. The data were compared to the WHO recommendations on physical activity for health. Whether factors in the fear-avoidance model were associated with physical activity was evaluated by two different multiple linear regression models. Results Ninety-six patients (83%) did not reach the WHO recommendations on physical activity for health, and 19 (16%) patients took fewer than 5000 steps per day, which indicates a sedentary lifestyle. On a group level, higher scores for fear of movement and disability were associated with lower numbers of steps per day. Conclusion A high proportion of the patients did not reach the WHO recommendations on physical activity and are therefore at risk of poor health due to insufficient physical activity. We also found a negative association between both fear of movement and disability, and the number of steps per day. Action needs to be taken to motivate patients to be more physically active before surgery, to improve health postoperatively. There is a need for interventions aimed at increasing physical activity levels and reducing barriers to physical activity in the prehabilitation phase of this patient group. Trial registration Current Controlled Trials ISCRTN 17115599, retrospectively Registered 18 may 2015

Use of the PREPARE (PREhabilitation, Physical Activity and exeRcisE) program to improve outcomes after lumbar fusion surgery for severe low back pain: a study protocol of a person-centred randomised controlled trial

BACKGROUND: Following lumbar fusion surgery, a successful outcome is empirically linked to effective rehabilitation. While rehabilitation is typically postoperative, the phase before surgery – termed prehabilitation – is reportedly an ideal time to prepare the patient. There are presently no guidelines for prehabilitation before lumbar fusion surgery. Physical activity has well-known health benefits, and staying physically active despite pain is a major principle in non-pharmacological chronic low back pain treatment. Psychological factors such as fear of movement, pain catastrophizing and low self-efficacy are known to be barriers to staying active. No studies have investigated prehabilitation protocols that promote physical activity and target psychological risk factors before lumbar fusion surgery. The aim of our proposed randomised controlled trial is to investigate whether patients who undergo lumbar fusion surgery for degenerative disc disease experience better functioning with a physiotherapeutic prehabilitation program (PREPARE) based on a cognitive behavioural approach compared to conventional care. METHODS/DESIGN: We will recruit 110 patients between 18–70 years of age with degenerative disc disease who are waiting for lumbar fusion surgery. These patients will be randomly assigned to receive either PREPARE or conventional care. PREPARE uses a person-centred perspective and focuses on promoting physical activity and targeting psychological risk factors before surgery. The primary outcome will be disability measured using the Oswestry Disability Index 2.0. Secondary outcomes will include functioning (patient-reported and performance-based), physical activity (accelerometer), health-related quality of life, back and leg pain intensity, pain catastrophizing, kinesiophobia, self-efficacy, depression, anxiety, satisfaction with treatment results and health economic factors. Data will be collected at baseline (preoperatively) after the intervention (preoperatively), 3 and 8 weeks, 3, 6, 12, 24 and 60 months postoperatively. DISCUSSION: We hypothesise that the focus on promoting physical activity and targeting psychological risk factors before surgery will decrease disability and help the patients to be more active despite pain both before and after surgery. We will use a combination of outcome measures both patient-reported and performance-based, as well as accelerometer data. This will provide a more comprehensive picture of the patient’s functioning than just patient-reported outcomes alone. TRIAL REGISTRATION: Current Controlled Trials ISCRTN17115599, Retrospectively Registered 18 May 2015