accelerated rehabilitation after lumbar discectomy

Accelerated

rehabilitation for

discectomy

patients Stephen Boyd – Physiotherapist

Nathan Wade – Exercise Physiologist

The reasoning

The reasoning

Case 1

• 32-year-old male

• employed as excavator operator

• 10 days unbearable sciatica

• unable to sleep

• large doses of analgesics

• disc herniation on MRI

• discectomy surgery

The reasoning

Case 1

Seen at 6 days post-op (Barricaid filming)

• minimal pain

• functioning equivalent to 3 week stage

• accelerated rehabilitation implemented

The reasoning

Case 1

2 weeks post-op

• minimal pain

• returned to full duties using excavator

• OTC medications

• returned to all normal activities

The reasoning

Pre-op 2 weeks post-op

The reasoning

Case 2

• 39-year-old male

• employed as a barge deckhand

• WorkCover claim

• 5 month history of sciatica

• failed to settle with injections

• large disc herniation on MRI

• discectomy surgery

The reasoning

Case 2

Seen at 10 days post-op

• early review as wanted to return to work

• minimal pain

• cleared for work

The reasoning

Pre-op 10 days post-op

The reasoning

Case 2

Seen at 6 weeks post-op

• reported that had worked 30 days straight

• performed full duties as a deckhand

• minimal pain

• OTC medications

The reasoning

Case 3

• 25-year-old stock filler

• Back and leg pain after lifting and twisting

• WorkCover patient

• Typical presentation and surgery

• Red flags

• Prolonged recovery

Not suitable for accelerated rehabilitation

The reasoning

Pre-op 3 months post-op

The evidence

The evidence

Caragee et al. (1996)

“lifting of post-operative activity

restrictions allowed shortened time

to return to work”

“average work loss was 1.2 weeks”

Kjellby-Wendt & Styf (1998)

“Patients rehabilitated

according to the early

active training program

(commenced 1 day post-

op) had a better short-term

outcome of objective

values”

McGregor, Burton, Sell (2007)

“early activation and return to

full activities as soon as possible

produces better relief of pain,

and return to work”

The evidence

Caragee et al. (1996)

“very early return to work did not

correlate with either recurrent

sciatica, reherniation or clinical

outcome”

McGregor, Burton, Sell (2007)

“early rehabilitation programmes

may improve function”

“early return to work is not

harmful, it can be helpful”

Newsome et al. (2009)

“Immediate commencement of exercise

following lumbar microdiscectomy enabled

patients to return to work sooner”

“no increase in the rate of revision surgery”

Our evidence

Out of the 257 discectomy surgeries

performed in 2012-2013 the revision rate at 12

months was 3%.

Only 3 recurrences (1%) occurred in the first 6

weeks.

• 1 occurred in hospital at 4 days post-op

• 1 occurred 5 days post-op

• 1 occurred 4 weeks ago

None were activity related

The process

The future

• Goal based vs time based

• Web based videos

http://www.spineplus.com.au/patient-

info/rehabilitation/spineplus-accelerated-

rehabilitation-program/discectomy-accelerated-

rehabilitation-videos/

• Regular communication (Skype)

The future

The future

Immediate (stage 1)

Progress to stage 2

The future

Stage 2

Progress to stage 3

The future

Post-operative

rehabilitation app