Heidi Prather, professor, chief of Section, Physical Medicine and Rehabilitation Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA, spoke at NASS about “What we know about postoperative training in the spine patient”. She talked to Spinal News International about this topic.
In your view, is postoperative training following spinal surgery important?
My belief is yes.
What are the goals of postoperative training?
The common sense answer to the patient is: “Make the most of the surgery you elected to have and now need to recover from, with the ultimate endpoint to reduce pain and improve function.”
The focus of surgery is to fix a structural problem thought to be related to signs and symptoms. In some cases, once the structural disorder is “fixed,” the problem is solved. Unfortunately, not every case works that way. Postoperative training needs to include interventions that are mindful of the healing process required of the structural treatment, while also considering pain and function. These “interventions” have not been standardised in the postoperative patient.
What are the approaches to postoperative training?
Most approaches to postoperative care have been focused on therapeutic exercise with varying degrees of specificity. Approaches to postoperative training in clinical practice are commonly linked to protocols handed down by the surgeon that are geared towards insuring healing of the operated structure and are based on the type of procedure performed. As a result, approaches to postoperative care are quite variable and can include severe restrictions in movement and activities to no recommendations. The literature is somewhat sparse to guide us with what is the “right” approach. Again, common sense would suggest that if hundreds of thousands of people undergo surgery every year in the USA and we do not have the answer to the question “which one is right?”, it is likely that the “right” answer is multifactorial and there is not just one answer.
After taking into consideration what is necessary for structural healing, if we ask the question, “What does the patient need?” in the postoperative period, we will come up with the approach(es) that would best be applied. Recognising that people are built (structurally and biologically) and wired (neuromuscular control, psychosocial response to pain and emotional challenges) differently is the battle. But once recognised, these varying patient characteristics explain why there are varying degrees of successful outcomes of an L4–L5 discectomy performed by an expert surgeon.
To the point of response to pain, in a podium presentation at the 2012 NASS annual meeting, VanDillen and colleagues applied a standardised model of inducing pain in asymptomatic volunteers. The pain response and functional limitations were variable. This suggests that some people come to the table equipped with the “tools” to handle a painful experience and others are not as equipped. It was not the length of time or type of injury. It was in the “wiring”. Even more impressive, VanDillen’s lab is one that studies movement and movement impairments with application of correcting movement aberrancies as treatment for people with low back pain. They are not experts in psychology and they figured it out. We clinicians need to get uniformly onboard with this concept.
At the same meeting, Paul Hodges showed the audience that the mechanisms of movement and response to pain and trauma are closely related and that retraining the brain “muscle” is as important, if not more important, than retraining the back muscle. His work is way ahead of the clinical world. Hopefully we clinicians can play catch-up as his lab continues to bring us more evidence regarding mechanisms as to why pain and dysfunction happen.
Should all patients undergo postoperative training, or are some patients more suitable than others?
Commonly, the suitable patient for postoperative treatment is the one who has pain and function goals that have not been attained by the surgery alone. Unfortunately, this can be an after-thought months after the procedure. However, not every patient needs the same intensity of care postoperatively. Hence, employing the same method on every patient may be unnecessary. A more reasonable approach would seem to be to have established “milestones” to be achieved during the healing process. An unachieved milestone might then trigger additional care, if needed, by the patient’s circumstance. Some surgeons have this approach to treatment but vary from surgeon to surgeon and are not standardised.
What are the potential problems of postoperative training (ie. poor advice/not following advice)?
A pitfall of postoperative care is poor communication between the surgeon and the healthcare provider providing the instruction to the patient. Transparency of what activities and movement that can and cannot be performed during weeks and months after surgery is important for all involved. A patient can become fearful and untrusting if he or she is instructed to “not bend” by the surgeon but the physical therapist instructs the patient to “bend “by moving through the hips. Educating the patient with clarity is essential.
The patient clearly has to be self-motivated to remain compliant with activity restrictions initially and then rebuilding strength, balance and coordination following a period of immobility. The rebuilding stage is an important time for the patient to have access to health care providers with expertise in regaining as much as possible. Not uncommonly, patients “settle” for the results they have after the immobilisation stage. This is where there is a great opportunity for the advancement of postoperative care.
What potential fears do patients have about postoperative training and how can they be reassured?
Patients can be fearful of performing activities or movement that will “undo” the surgery. Others can be fearful that the pain and function restrictions they experience in the immediate post-operative period will continue. In both circumstances, education by healthcare providers is important to insure that the questions the patient has are answered. Answered questions early on may help reduce fear avoidance later. Fear avoidance has clearly been linked to chronic pain.
Are there formal guidelines on what postoperative training should involve? If not, should there be?
In my opinion, there should be a standardised “road map” for both the patient and surgeon to guide them through the postoperative period. The literature available today has enough holes in it that a guideline with high-level studies is currently not available for every type of procedure.
If monies for studying the postoperative spine patient were unlimited, I would suggest a plan of study that was centred on the patient’s comprehensive needs, rather than the type of procedure performed. This would include recognising the length of time and type of impairments that the patient dealt with prior to surgery, the behavioural and cognitive needs and limitations, the type of procedure and the impairments that remained post-procedure and the length of time and degree of immobilisation required for structural healing. Milestone accomplishments for each of these in a standardised application would ensure that patients would get the amount of “training” based on individual needs while maintained a baseline standard for every patient. If a standardised patient-centred approach promoted even a 5–10% improvement in pain and function, this would be significant. A procedure with a success rate of 80% could improve to 85–90%. Everyone wins. Just one grandiose thought.