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Physical Therapy Following Anterior Cervical Discectomy and Fusion: A Study of Current Clinical Practice and Therapist Beliefs

Authors:

Abstract

Background: Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgical procedure. However, there is substantial debate regarding the role of physical therapy following this procedure. Therefore, we sought to determine current physical therapy practice following ACDF surgery, as well as determine physical therapists beliefs regarding rehabilitation following ACDF. Methods: One hundred and eighty three licensed Physical Therapists were invited to participate in a descriptive internet based survey; a total of 53 (29%) completed the survey. Physical Therapists were assessed for their current practice, asked to rate the clinical usefulness of various treatment modalities, and indicate their recommendations regarding post-operative physical therapy for subjects following anterior discectomy and fusion. Results were then assessed for frequency distributions, with chi-square analysis for association between demographic data and practice recommendations. Results: The results indicate that Physical Therapists believe patients achieve superior outcomes with the inclusion of post-operative physical therapy, with a low risk of harm. Specific treatments indicated as most useful included endurance exercise (60.4%), isometric strengthening (56.6%), and stretching (45.3%). Other treatment options are discussed in detail. Conclusion: Physical Therapists identified specific activities that they felt were most appropriate for rehabilitation following ACDF surgery. These findings may help to direct both appropriate therapy prescription following ACDF, as well as future research.
Int J Physiother 2015; 2(2) Page | 399
1Brian T. Swanson
2Robin R. Leger
CORRESPONDING AUTHOR
1Brian T. Swanson
PT, DSc, FAAOMPT
Texas Woman’s University,
School of Physical Therapy,
Houston, TX, USA.
Int J Physiother. Vol 2(2), 399-406, April (2015) ISSN: 2348 - 8336
ABSTRACT
Background: Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgical
procedure. However, there is substantial debate regarding the role of physical therapy following this
procedure. Therefore, we sought to determine current physical therapy practice following ACDF
surgery, as well as determine physical therapists beliefs regarding rehabilitation following ACDF.
Methods: One hundred and eighty three licensed Physical Therapists were invited to participate in a
descriptive internet based survey; a total of 53 (29%) completed the survey. Physical Therapists were
assessed for their current practice, asked to rate the clinical usefulness of various treatment modalities,
and indicate their recommendations regarding post-operative physical therapy for subjects following
anterior discectomy and fusion. Results were then assessed for frequency distributions, with chi-square
analysis for association between demographic data and practice recommendations.
Results: The results indicate that Physical Therapists believe patients achieve superior outcomes with
the inclusion of post-operative physical therapy, with a low risk of harm. Specific treatments indicated
as most useful included endurance exercise (60.4%), isometric strengthening (56.6%), and stretching
(45.3%). Other treatment options are discussed in detail.
Conclusion: Physical Therapists identified specific activities that they felt were most appropriate for
rehabilitation following ACDF surgery. These findings may help to direct both appropriate therapy
prescription following ACDF, as well as future research.
Keywords: Cervical spine surgery, ACDF, physical therapy, practice patterns, evidenced-based practice.
2 RN, MS, PhD
Associate Professor, Graduate School
of Nursing, Salem State University,
Salem, MA, USA.
Received 28th February 2015, revised 27th March 2015, accepted 31st March 2015
DOI: 10.15621/ijphy/2015/v2i2/65249
www.ijphy.org
Int J Physiother 2015; 2(2) Page | 400
INTRODUCTION
Anterior cervical decompression and fusion (ACDF)
has been shown to be successful in the
management of cervical disc disease.1 While there
is general agreement among both physicians and
physical therapists that patients undergoing
cervical spine surgery need regular follow up,
postsurgical rehabilitation recommendations
following cervical spine surgery have not been well
established. Physical therapy is commonly utilized
during both the pre and post-operative period, with
approximately 70% of surgeons regularly utilizing
physical therapy services, according to our previous
survey of the members of the North American Spine
Society.² Despite being frequently used, the effect
of rehabilitation following ACDF on patient
reported outcomes is unknown.
Few prospective studies have been published with
respect to outcomes and disability following ACDF.3
While generally successful in the treatment of
radicular symptoms, with over 75% reporting relief
at 2 years post-operatively,4-6 it is not uncommon
for patients to remain otherwise symptomatic.4
Peolsson et al 3prospectively evaluated a group of
patients undergoing ACDF and found only 5 of 34
(15%) patients were without complaints of neck
problems according to the Neck Disability Index
(NDI), pain scores, and general health measures at
1 year postoperatively. The prevalence of neck
related disability prompted the authors to conclude
that improved surgical techniques and
postoperative rehabilitation are greatly needed.
With an increase of greater than 200% in the
volume of cervical spine surgeries performed over
the last decade, evidence based practices for
cervical spine surgeries are becoming increasingly
more important.7 In the current climate of cost
reduction, utilization of rehabilitative services is
being examined closely, particularly in situations
where there is a lack of evidence regarding their
short and/or long term benefits. In particular, there
is little data available regarding the best physical
therapy practices in this post-operative population.
Therefore, to facilitate recommendations for
clinical trials or other critical studies regarding
postsurgical rehabilitation, we sought to determine
the current practice patterns of physical therapists
regarding postsurgical rehabilitation techniques
and recommendations following cervical spine
surgery.
Sample
Participants were recruited from two private
physical therapy practice groups (Select Medical
Corporation, New England region n=100, Physical
Therapy and Sports Medicine Centers of CT n=35),
and the membership of the Connecticut Physical
Therapy Associations Orthopedics and Manual
Therapy special interest group n= 48. Potential
subjects received an e-mail inviting them to
participate, which contained a link to the on-line
survey as well as information regarding the
deadline for completion. Participants were
informed that the survey would take approximately
10 minutes to complete and that the information
gathered for the study was confidential and
anonymous. Participants were sent two reminders
over a period of two months to aide in recruitment.
METHODS
The authors developed an internet based survey
similar to the survey conducted with the surgical
members of the North American Spine Society. 2
Subjects completed an internet based survey
consisting of 21 questions. The first portion of the
survey contained questions regarding demographic
and training characteristics, including fellowship or
residency training, length of the time since the
completion of training, specialization, type of
practice (academic, private practice, hospital,
multispecialty group, other), therapist age, and
yearly volume of cervical spine post-operative
rehabilitation procedures performed by the
individual therapist. The second part of the survey
contained questions pertaining to therapist beliefs
regarding rehabilitation following ACDF, and the
final section contained questions regarding the
frequency and duration of postsurgical
rehabilitation and specific intervention
recommendations following cervical spine surgery.
Prior to distribution of the survey, the tool was
reviewed by two independent practitioners, one a
spine surgeon, one a physical therapist with
orthopedic specialist certification for content
validation.
Responses were analyzed using uni-variate
statistical analyses, including frequencies of
responses for categorical variables. Frequency
distributions were created for all response variables
and bi-variate cross-tabulations were used for
comparisons of selected demographic variables
with selected practice variables. When appropriate,
original responses were collapsed into fewer
categories. Chi square tests were used to compare
associations between demographic variables and
practice-related responses. Finally, a Spearman rho
correlation was used to assess the relationship
between demographic variables and practice
recommendations. All calculations were completed
using SPSS Version 16 (IBM SPSS Statistics, Rel.
19.0.0. 2010. Chicago: SPSS Inc., an IBM Company).
An alpha-level of <0.05 was chosen a priori as the
Int J Physiother 2015; 2(2) Page | 401
threshold for statistical significance and maintained
due to the descriptive nature of the study,
RESULTS
A total of 53 subjects completed the e-mail survey tool, for a total response rate of 29%. Therapist
demographics are contained in Table 1.
Table - 1: Demographics and Training Characteristics of Physical Therapists (N=53)
Age
Frequency
21-30
21
39.6
31-40
19
35.8
41-50
8
15.1
51-60
5
9.4
Years in practice
0-5 years
18
34.0
6-10 years
12
22.6
11-15 years
6
11.3
16-20 years
7
13.2
20-25 years
6
11.3
25+ years
4
7.5
Practice setting
academic institution
3
5.7
private practice
33
62.3
multispecialty group
5
9.4
HMO
2
3.8
Other
10
18.9
Board Certified Clinical
Specialist (OCS,SCS)
Yes
9
17.0
No
44
83.0
Fellowship/Residency
Training
Fellowship/residency
7
13.2
No fellowship/residency
46
86.8
Across all groups, the majority of therapists (58.5%)
started therapy in the 4-6 week range, and typically
treat patients following ACDF two sessions per
week(66.0%). There were no statistically significant
differences comparing treatment frequency or start
time for practice setting, years of practice, age
group, fellowship/ residency training or clinical
specialization. (Table 2)
Table 2: Initiation and Frequency of Therapy (N = 53)
Sessions per week
Frequency
Percentage
2
35
66.0
3
15
28.3
4
1
1.9
5
1
1.9
missing data
1
1.9
Start Time
first week
1
1.9
2-3 weeks
14
26.4
4-6 weeks
31
58.5
pain controlled
1
1.9
radiographic healing
4
7.5
Missing
2
3.8
Int J Physiother 2015; 2(2) Page | 402
The majority of therapists (52.8%) across all groups
continue therapy for 4-6 weeks, with 6-8 weeks also
occurring frequently (30.2%). There was a
statistically significant difference for fellowship/
residency trained therapists tending to continue
therapy longer than non-fellowship/residency
trained therapists (χ²=9.92, p=.019, +LR 8.70).
There was no statistically significant difference in
start timing or sessions per week between
fellowship/residency trained therapists and non-
fellowship/residency trained therapists. There was
an association for specialists to see patients fewer
times per week (χ²=10.74, p=.013, +LR= 8.50),
and for therapists with more than 25 years of
experience to see patients more frequently (χ²=
28.01, p=.022, +LR = 19.99). Additionally, there
was an association between seeing a higher volume
of post operative cases and more sessions per week
(χ²= 23.44, p=.024, +LR= 14.01). There were no
statistically significant associations between
practice setting or age and the start of therapy, visits
per week, or length of continuation of therapy.
Appropriate treatment options
Physical therapists who participated were
presented with a list of 11 common treatment
modalities, and asked to select from this list the
treatments that they deemed to be appropriate for
patients following ACDF, and then a duplicate list
asking them to select those that they deemed
inappropriate for patients following ACDF. The
selected treatments are presented in Table 3.
Table 3: Appropriateness of therapeutic modalities
Deemed appropriate
Deemed inappropriate
Response
Percent
Response
Count
Response
Percent
Response
Count
Moist Heat
86.5%
45
5.8%
3
Isometric
Strengthening
86.5%
45
9.6%
5
Endurance
exercises
73.1%
38
7.7%
4
Stretching
exercises
71.2%
37
7.7%
4
Aerobic exercise
63.5%
33
5.8%
3
Massage
61.5%
32
11.5%
6
Electrical
stimulation
59.6%
31
21.2%
11
Joint
mobilization
40.4%
21
40.4%
21
Ultrasound
26.9%
14
51.9%
27
Aquatic therapy
21.2%
11
7.7%
4
Traction
5.8%
3
90.4%
47
Treatment prioritization
The therapists were given a list of 11 common
treatments utilized in the treatment of patients in
the outpatient setting. They were instructed to rate
the interventions on a scale of 1-4, with 1 being not
at all important and 4 being very important. The
majority of therapists from the total sample
identified several treatments as being very
important in the care of patients following ACDF.
The primary treatments included endurance
exercise (60.4%), isometric strengthening (56.6%),
and stretching (45.3%). Secondary treatments,
defined as somewhat important, included aerobic
activity (somewhat 45.3%, very 35.8%, cumulative
81.1%), massage (somewhat 58.5%, very 18.9%,
cumulative 77.4%), and moist heat (somewhat
45.3%, very 17%, cumulative 62.3%). Those rated
primarily as “not at all important” were traction
(77.4%) and ultrasound (60.4%). Mobilization,
aquatic therapy and electrical stimulation were
considered neutral recommendations, with greater
than 50% of respondents rating these interventions
as slightly or somewhat important. (Table 4)
Table 4: Therapist rankings of interventions
Int J Physiother 2015; 2(2) Page | 403
Very
important
Somewhat
Important
Slightly
Important
Not at all
Important
N
%
n
%
N
%
N
%
Endurance
32
60.4
13
24.5
7
13.2
0
0
Isometric
Strength
30
56.6
16
30.2
4
7.5
3
5.7
Stretching
24
45.3
16
30.2
10
18.9
2
3.8
Aerobic
Activity
19
35.8
24
45.3
10
18.9
Joint
Mobilization
10
18.9
13
21.5
12
22.6
15
28.3
Massage
10
18.9
31
58.5
7
13.2
4
7.5
Moist Heat
9
17.0
24
45.3
13
21.5
7
13.2
Electrical
Stimulation
6
11.3
18
34.0
13
21.5
11
20.8
Aquatic
2
3.8
12
22.6
22
41.5
13
21.5
Traction
2
3.8
3
5.7
2
3.8
41
77.4
Ultrasound
1
1.9
9
17.0
9
17.0
32
60.4
There was a significant association between
fellowship or residency training and the
prioritization of joint mobilizations (χ²= 8.40, p=.
038, +LR= 8.99). Specialists considered stretching
to be a lower priority intervention compared to non-
specialists (χ²=12.11, p=.007, +LR =10.91). There
was a strong association for those identifying as
working in private practice, academic settings and
other as considering isometric strengthening
important compared to those identifying as working
for an HMO (χ²= 30.26, p=.003, -LR=18.06).There
were no other statistically significant associations
between groups and specific interventions.
There were several significant correlations between
demographic variables and treatment prioritization.
Amongst the demographic variables, years of
practice was negatively correlated to specialist
status, (r=-.374, p=.006), however there were no
other statistically significant relationships between
years of practice, specialist certification, and
fellowship status. Therapists who prioritized
endurance activity also selected aerobic exercise as
an important treatment aspect, (r=.557, p<.001).
This finding was not significantly related to
specialist status, years in practice, or fellowship
status. Despite the general response regarding
modalities being appropriate but of lower priority,
there was a strong relationship for therapists who
indicated that ultrasound was important also
indicating that electrical stimulation (r=.450,
p=.001) and moist heat (r=.397, p=.004) were also
important. However, there was a moderate to
strong relationship between prioritizing
mobilizations and avoiding moist heat (r=-.349,
p=.013). These findings did not correlate to years
of practice, or specialist certification, but modality
use was correlated to a lack of fellowship training
(ES r=.350, p=.015, US r=.278, p=.048, MH
r=.344, p=.012). Inclusion of isometric exercises
was negatively correlated to the length of
continuation of therapy, (r=-.303, p=.029) without
relationship to demographic factors. However,
fellowship training also had a moderate negative
correlation to length of continuation of therapy (r=
-.395, p=.004).
Therapist Beliefs Regarding Rehabilitation
Following ACDF
The therapists were asked to rate their beliefs on a
scale of 1-5, with 1 indicating strongly disagree and
5 indicating strongly agree with a series of
statements.
In response to the statement “I believe that physical
therapy is beneficial to the patient following
cervical fusion surgery”, 57.7% (n=30) indicated
strongly agree, 36.5% (n=19) indicated agree, 3.8%
(n=2) indicated neutral, and 1.9% (n=1) strongly
disagreed.
In response to the statement “I believe that physical
therapy may be harmful to the healing of the
fusion”, no participants responded strongly agree,
5.9% (n=3) indicated agree, 7.8% (n=4) indicated
neutral, 64.7% (n=33) indicated disagree, and
21.6% (n=11) indicated strongly disagree.
In response to the statement “I believe that the
patient is able to recover full function without post
operative intervention”, no participant responded
strongly agree, 9.6% (n=5) agreed, 34.6% (n=18)
indicated neutral, 42.3% (n=22) indicated disagree,
and 13.5% (n=7) indicated strongly disagree.
In response to the statement “My patients have had
negative experiences with post-operative physical
therapy”, no participant responded strongly agree,
Int J Physiother 2015; 2(2) Page | 404
3.8% (n=2) indicated agree, 7.7% (n=4) indicated
neutral, 53.8% (n=28) indicated disagree, and
34.6% (n=18) indicated strongly disagree.
In response to the statement, “Patients have better
outcomes with the inclusion of post-operative
physical therapy”, 44.2% (n=23) indicated strongly
agree, 46.2% (n=24) indicated agree, 7.7% (n=4)
indicated neutral, and 1.9% (n=1) indicated s
trongly disagree. There were no statistically
significant associations between response and any
grouping for age, fellowship/residency training,
practice setting, clinical specialist status, or years of
practice across all measures for therapist belief.
Correlations of beliefs
Therapist response that therapy is beneficial to the
patient was strongly correlated to patients having
improved outcomes with post operative therapy,
r=.591, p<.001. This response was negatively
correlated to believing that patients could achieve
full function without post operative care (r=-.412,
p-.002), as well as reporting that patients have had
negative experiences with therapy (r=-.527,
p<.001). Responses indicating that patients achieve
superior outcomes with therapy also demonstrated
a negative correlation to believing that patients
could achieve full function without post operative
care (r=-.500, p<.001), as well as reporting that
patients have had negative experiences with
therapy (r=-.416, p=.002). However, for therapists
reporting that they felt therapy may be harmful to
the fusion, there was a statistically significant
correlation to reporting that their patients have had
negative outcomes as a result of therapy (r=.284,
p=.041).
DISCUSSION
The purpose of this study was to establish physical
therapists current practice patterns and beliefs
regarding rehabilitation following ACDF,
establishing data regarding usual physical therapy
care during the post-operative period. To our
knowledge, there has not been specific research
performed to determine either the role of physical
therapy following ACDF surgery or the types of
therapy performed. Therefore, establishment of
baseline data is required to develop appropriate
protocols for comparison of various modes of care
for use in post-operative rehabilitation studies.
The results of this study revealed several trends in
clinical care following ACDF. Therapists strongly
believed that post-operative rehabilitation results in
improved functional outcomes that would not have
been attained by the patient on their own. This is
in line with the current evidence suggesting that
while pain is resolved following ACDF, other
deficits remain.1,6,8 Therapists emphasized the use
of active rehabilitation featuring endurance
exercises, isometric strengthening, stretching, and
aerobic activity, while placing a lower emphasis on
passive modalities. The majority of respondents
reported initiation of therapy between 4-6 weeks. As
most patients would then be beyond the acute stage
of healing, pain management may be a lower
priority, and passive modalities may be under-
represented as a result. Interestingly, while the
majority of therapists deemed modalities to be
appropriate, very few placed a high priority on their
usage in this population. Those therapists
indicating a higher priority of ultrasound, however,
were also likely to place a high priority on moist
heat and electrical stimulation. This may represent
an alternative practice pattern for this post
operative population.
We were unable to identify any randomized trials
evaluating the effects of physical therapy during the
post-operative period following cervical spine
surgery. Findings from observational studies have
elucidated various factors related to disability
following ACDF. Previous research9 found an
association between decreased neck muscle
endurance and continued pain and disability
following ACDF. Neck muscle endurance (NME)
deficits were directly correlated to higher levels of
disability suggesting that specific training for NME
should be incorporated into the rehabilitation
program. Additional studies3examined short term
results following ACDF (6 months) to see if long
term results (3 years) could be predicted. At three
years after ACDF, approximately two-thirds of the
patients had deficits related to pain intensity and
function. These findings led to the conclusion that
while these problems are multi-factorial, the
inclusion of strength and endurance activities may
improve long-term outcome.
Based on the consensus of respondents, there is a
strong feeling that patients benefit from the
inclusion of post-operative rehabilitation. The
specific recommendations included endurance
exercises, isometric strengthening, stretching,
aerobic activity, and to a lesser extent massage and
moist heat. These active treatment interventions
appear to be specifically targeted at restoring
function rather than provide symptomatic relief.
This also coincided with a strong recommendation
away from passive modalities such as ultrasound
and traction in the post-operative period.
Incorporating appropriate active rehabilitation
following fusion may lead to better results and
decreased overall expenditures. As such, our
findings are in agreement with the suggestions of
previous authors.
Int J Physiother 2015; 2(2) Page | 405
Manual therapy has been supported by the best
available evidence for the treatment of cervical
radiculopathy,10,11 however there seems to be a
general lack of consensus regarding the use of joint
mobilizations following ACDF. In fact, our sample
presented with a near equal distribution of answers
regarding the prioritization of its use. While
certainly contraindicated at the level of fusion,
there may be a role for manual therapies directed at
the surrounding levels/tissues. Current theories,
including regional interdependence12,13, as well as
the neurophysiologic effect of manual therapies on
pain modulation14 may justify a role for such
techniques in the management of patients following
ACDF. The association of mobilization use with
fellowship-residency training may represent a
selection bias, as these individuals are more likely
to have specialized training in the use of manual
therapy techniques. This training, however, would
also qualify these individuals the experts in the use
of these techniques, and may indicate an area in
need of further study.
In our sample, there was an association for
specialists to see patients fewer times per week.
This corresponds to previous findings regarding the
care of neck pain relative to education. Magel et al15
reported that the number of sessions of care
decreased in response to specific education
regarding care of neck pain. Conversely, in the
current study, therapists indicating >25 years of
experience was strongly associated with seeing
patients more frequently. While we could find no
direct data associating experience to therapy
utilization, prior research has reported on the
association of experience to evidence based
practice. 16Their findings indicated a strong
association with younger/less experienced physical
therapists utilizing evidence and performing critical
appraisal to aide their practice, while progressive
years of experience were associated with a
decreased use of evidence. They reported that
therapists with <5yrs experience reported a 4.6x
greater use of evidence when compared to
therapists with 15yr+ years of experience.
Concurrently, therapists in the 20-29 year old range
reported that they were 22.7x more likely to have
received formal training in critical appraisal when
compared to therapists in the 50yo+ category. The
current study population demonstrated a negative
correlation between years in practice and specialist
certification. As a result, the reported high levels of
therapy utilization in the more experienced group
may be related to the reported trend towards lower
levels of evidenced based practice.
There were several limitations for this study. The
survey was only issued to a single geographic
region, and may have detected only local practice
patterns. These patterns and beliefs may not be
those of therapists in other regions. While intended
to determine current practice, our survey did not
differentiate whether treatment choice was at the
therapist’s discretion or if it was prescriptive in
nature, nor did we attempt to differentiate
treatment choice based on the immediate goals of
treatment, instead focusing on a more global view
of ACDF rehabilitation. Our sample was heavily
weighted towards therapists in a private practice
setting, and one-third of respondents were novice
practitioners with less than 5 years of experience.
It should therefore be noted that due to a limited
sample size, as well as a possible selection bias from
the sample of convenience who chose to
participate, these findings may not be applicable to
all rehabilitative settings. While the response rate
of 29% was better than generally expected for a
survey instrument, and the overall sample of 53 is
large enough to allow for some generalizations to be
made, there is also a possibility of selection bias, as
those who chose to respond may have different
practice patterns and beliefs than those who chose
not to respond. Finally, the survey instrument
utilized to perform this study has not been subjected
to statistical validation.
CONCLUSION
The results of the study indicate several
recommendations for the utilization of physical
therapy following ACDF. Over 90% of therapists
surveyed believe that therapy is beneficial for the
patient following ACDF. Therapy is utilized in
most cases twice weekly, and for 6 weeks duration.
During these sessions, the focus is on endurance
exercises, isometric strengthening, stretching,
aerobic activity, and to a lesser extent massage and
moist heat. These active treatment interventions
appear specifically targeted to regain function
rather than provide symptomatic relief. Future
research to examine the efficacy of postoperative
rehabilitation in improving clinical outcomes and
preventing disability in patients who have
undergone ACDF is needed.
Acknowledgements: The authors would like to
thank Ms. Lindsay McDermott and Mr. Mark
Gombotz of Select Medical Corp. and Mr. Michael
Gans of Physical Therapy and Sports Medicine
Centers/Connecticut Physical Therapy Association
OMT SIG for their assistance in the recruitment of
participants for this study, and Dr. Mark Cote for his
assistance in editing this paper. The authors also
thank R. Alexander Mohr, MD and Sean P. Riley PT,
ScD, OCS for their assistance in the content
validation for this survey.
Int J Physiother 2015; 2(2) Page | 406
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
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Citation
Brian T. Swanson, Robin R. Leger. (2015). PHYSICAL THERAPY FOLLOWING ANTERIOR CERVICAL
DISCECTOMY AND FUSION: A STUDY OF CURRENT CLINICAL PRACTICE AND THERAPIST
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... 7,8 Variability in the utilization of rehabilitation after ACDF may contribute to these poor outcomes. 9 Rehabilitation is often initiated 4 to 6 weeks after surgery. 9 However, two systematic reviews highlight a lack of evidence for guiding postoperative rehabilitation. ...
... 9 Rehabilitation is often initiated 4 to 6 weeks after surgery. 9 However, two systematic reviews highlight a lack of evidence for guiding postoperative rehabilitation. 10,11 One randomized trial has shown rigid collars improve function and pain after ACDF, but the quality of evidence was very low. ...
... The most common time to begin PT is 4 to 6 weeks after ACDF, 9 likely reflecting safety considerations. The current study, however, offers preliminary data on early exercise safety. ...
Article
Study design: Pilot randomized controlled trial. Objective: To examine the acceptability and preliminary safety and outcome effects of an early self-directed home exercise program (HEP) performed within the first six weeks after anterior cervical discectomy and fusion (ACDF). Summary of background data: Little is known regarding optimal postoperative management after ACDF. Methods: Thirty patients (mean ± SD age = 50.6 ± 11.0 years, 16 females) undergoing ACDF were randomized to receive an early HEP (n = 15) or usual care (n = 15). The early HEP was a 6-week self-directed program with weekly supportive telephone calls to reduce pain and improve activity. Treatment acceptability was assessed after the intervention period (6 weeks after surgery). Safety (adverse events, radiographic fusion, revision surgery) was determined at routine postoperative visits. Disability (Neck Disability Index), pain intensity (Numeric Rating Scale for neck and arm pain), physical and mental health (SF-12), and opioid use were assessed preoperatively, and at 6 weeks and 6 and 12 months after surgery by an evaluator blinded to group assignment. Results: Participants reported high levels of acceptability and no serious adverse events with the early HEP. No difference in fusion rate was observed between groups (p > 0.05) and no participants underwent revision surgery. The early self-directed HEP group reported lower 6-week neck pain than the usual care group (F = 3.3, p = 0.04, r2 = 0.3, mean difference = -1.7 [-3.4; -0.05]) and lower proportion of individuals (13% vs. 47%) using opioids at 12 months (p = 0.05). No other between-group outcome differences were observed (p > 0.05). Conclusions: An early self-directed HEP program was acceptable to patients and has the potential to be safely administered to patients immediately after ACDF. Benefits were noted for short-term neck pain and long-term opioid utilization. However, larger trials are needed to confirm safety with standardized and long-term radiograph assessment and treatment efficacy. Level of evidence: 2.
... Больным, перенесшим декомпрессивно-стабилизирующие операции, широко применяется реабилитационное лечение [15,16], в том числе лечебная физкультура [17][18][19][20]. Методы медицинской реабилитации неуклонно совершенствуются, но способы оценки динамики мелкой моторики рук достаточно ограничены и субъективны, что осложняет объективную оценку эффективности проводимых мероприятий [21]. ...
Article
Full-text available
Aim. Improving the long-term results of surgical treatment requires not only timely diagnosis, but also self monitoring of the dynamics of impaired functions on the part of the patient. The aim of the study was to establish the reliability of the test by comparing its results with clinical data and information from electroneuromyography of the upper extremities in patients after decompression-ventral subaxial fusion. Material and methods. The presence of motor disorders reduction or loss of bicipital, tricipital and carporadial reflexes and electroneuromyography data was compared with the results of the method according to patent RU2717365C1 in 27 patients after decompression- ventral subaxial cervicospondylodesis due to diseases and injuries of the cervical spine. Results and discussion. It was found that the test was slowed down in patients with motor deficiency of the upper extremities with a corresponding level of damage to the performed reverse gesture. The same pattern with respect to the decrease or absence of appropriate reflexes, as well as the slowing down of the motor spine system according to the electroneuromyography. Conclusions. The test is quite sensitive and objective, can be recommended to patients for self-control. The use of this method for patients does not cancel the need for planned diagnostic measures and does not replace them. The development of such tests can help improve the selection of rehabilitation measures
... No guidelines exist for the timing of rehabilitation after ACDF surgery. Start times for rehabilitation are variable, but often occur 6 weeks following surgery due to the concern of interfering with successful fusion (Swanson and Leger, 2015). No study has examined the safety or feasibility of performing early exercise immediately after ACDF. ...
Article
Objective: To describe the safety, feasibility, and preliminary outcomes of an early telephone-supported home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF) surgery. Methods: Eight patients (mean ± SD age = 53.4 ± 14.9 years, 5 females) were enrolled in this case series. Immediately after surgery, patients began a 6-week HEP including daily walking, deep breathing, distraction techniques, and cervical and upper body exercises. The HEP was supported by weekly telephone calls by a physical therapist. Safety for performing early exercise was examined with radiographic imaging at 6 months. Adverse events were assessed through weekly calls with a physical therapist. HEP adherence and acceptability data were obtained by patient self-report. Clinical measures were assessed preoperatively, at 6 weeks and at 6 months, and included the Neck Disability Index, Numeric Rating Scale for pain, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and accelerometry for physical activity. Results: Early radiographic imaging showed no signs of nonunion at 6 months. There were no reports of serious adverse events. At 6 months, all patients reported clinically significant changes in pain catastrophizing. Seven (88%) patients had clinically significant changes in disability and arm pain, six (75%) patients for neck pain and pain self-efficacy, and five (53%) patients for fear of movement. Only three (43%) of seven patients showed increased physical activity at 6 months. Conclusion: Based on this small case series, an early telephone-supported HEP appears safe for patients, feasible to implement, and promising for clinical benefits.
Article
Full-text available
Few prospective studies on outcome have been conducted with respect to disability after anterior cervical decompression and fusion (ACDF), and the need for further rehabilitation after surgery is unknown. Thirty-four patients with cervical disc disease verified by magnetic resonance imaging were included before ACDF with a cervical carbon fibre intervertebral fusion cage. Measurements took place the day before, 6 months and 1 year after surgery, and consisted of both objective and subjective measurements. The results showed a significant improvement from surgery in neck muscle endurance in flexion, neck strength in lateral flexion, some of the pain variables, numbness, neck specific disability, change in general health and symptom satisfaction at the 1-year follow-up. Except for worsening in general health, there were no significant differences between the 6-month and the 1-year follow-up. Despite improvement in several of the variables, about one-third of the patients had deficits in the objective measurements and about two-thirds had deficits in the subjective variables. Only five patients were without neck problems according to average pain, the Neck Disability Index and general health. This suggests that there is still a great need for improvement both of the surgical procedure and the rehabilitation afterwards.
Article
Full-text available
Physical therapists often attend continuing education (CE) courses to improve their overall clinical performance and patient outcomes. However, evidence suggests that CE courses may not improve the outcomes for patients receiving physical therapy for the management of neck pain. The purpose of this study was to investigate the effectiveness of an ongoing educational intervention for improving the outcomes for patients with neck pain. The study participants were 19 physical therapists who attended a 2-day CE course focusing on the management of neck pain. All patients treated by the therapists in this study completed the Neck Disability Index (NDI) and a pain rating scale at the initial examination and at their final visit. Therapists from 11 clinics were invited to attend a 2-day CE course on the management of neck pain. After the CE course, the therapists were randomly assigned to receive either ongoing education consisting of small group sessions and an educational outreach session or no further education. Clinical outcomes achieved by therapists who received ongoing education and therapists who did not were compared for both pretraining and posttraining periods. The effects of receiving ongoing education were examined by use of linear mixed-model analyses with time period and group as fixed factors; improvements in disability and pain as dependent variables; and age, sex, and the patient's initial NDI and pain rating scores as covariates. Patients treated by therapists who received ongoing education experienced significantly greater reductions in disability during the study period (pretraining to posttraining) than those treated by therapists who did not receive ongoing training (mean difference=4.2 points; 95% confidence interval [CI]=0.69, 7.7). Changes in pain did not differ for patients treated by the 2 groups of therapists during the study period (mean difference=0.47 point; 95% CI=-0.11, 1.0). Therapists in the ongoing education group also used fewer visits during the posttraining period (mean difference=1.5 visits; 95% CI=0.81, 2.3). The results of this study demonstrated that ongoing education for the management of neck pain was beneficial in reducing disability for patients with neck pain while reducing the number of physical therapy visits. However, changes in pain did not differ for patients treated by the 2 groups of therapists. Although it appears that a typical CE course does not improve the overall outcomes for patients treated by therapists attending that course, more research is needed to evaluate other educational strategies to determine the most clinically effective and cost-effective interventions.
Article
Full-text available
Little research has been done regarding the attitudes and behaviors of physical therapists relative to the use of evidence in practice. The purposes of this study were to describe the beliefs, attitudes, knowledge, and behaviors of physical therapist members of the American Physical Therapy Association (APTA) as they relate to evidence-based practice (EBP) and to generate hypotheses about the relationship between these attributes and personal and practice characteristics of the respondents. A survey of a random sample of physical therapist members of APTA resulted in a 48.8% return rate and a sample of 488 that was fairly representative of the national membership. Participants completed a questionnaire designed to determine beliefs, attitudes, knowledge, and behaviors regarding EBP, as well as demographic information about themselves and their practice settings. Responses were summarized for each item, and logistic regression analyses were used to examine relationships among variables. Respondents agreed that the use of evidence in practice was necessary, that the literature was helpful in their practices, and that quality of patient care was better when evidence was used. Training, familiarity with and confidence in search strategies, use of databases, and critical appraisal tended to be associated with younger therapists with fewer years since they were licensed. Seventeen percent of the respondents stated they read fewer than 2 articles in a typical month, and one quarter of the respondents stated they used literature in their clinical decision making less than twice per month. The majority of the respondents had access to online information, although more had access at home than at work. According to the respondents, the primary barrier to implementing EBP was lack of time. Physical therapists stated they had a positive attitude about EBP and were interested in learning or improving the skills necessary to implement EBP. They noted that they needed to increase the use of evidence in their daily practice.
Article
A prospective follow-up study of patients with anterior cervical discectomy and fusion (ACDF) for single-level cervical disc disease was conducted to determine the extent of impact of pain, sensory function, motor function, and range of motion (ROM) of the neck on patient satisfaction after ACDF. A total of 67 ACDF patients were monitored by clinical examination (pain, motor function, sensory function, and ROM in the neck) preoperatively and at follow-up (mean, 217 d after surgery; range, 198 to 232 d) and by a satisfactory questionnaire (SQ) at follow-up only. According to the SQs, 4 patient groups were characterized. Inside each patient group for each examination parameter, the percentage of patients who showed improved, unchanged, or worsened clinical results was analyzed. Patient satisfaction was found to depend primarily on the improvement in pain (P=0.001). The development of motor function (P=0.056), sensory function (P=0.225), and ROM of the neck (P=0.565) did not demonstrate significant correlation with patient satisfaction. The Numerical Rating Scale score decreased from 6.2 before surgery to 2.1 on follow-up, whereas the level of analgesic use (World Health Organization scheme) decreased from 1.9 to 0.3. Improvement in pain seemed to be most important aspect in ACDF patients regarding the subjective SQ. Therefore, we strongly recommend focusing on pain-reducing therapies when choosing treatment for these patients during the postoperative period.
Article
Cervicobrachial pain is a common cervical spine disorder. It is frequently managed through non-invasive therapy. The objective of this systematic review was to assess effectiveness of non-invasive therapy for the management of cervicobrachial pain, in terms of pain, function and disability. Computerised searches were performed to January 2010. Studies were selected using pre-specified criteria. Methodological quality of included studies was assessed using PEDro and level of inter-reviewer agreement reported using Kappa values. Meta-analyses were conducted on pain scores for similar interventions using DerSimonian-Laird random-effects model to allow for heterogeneity. Effect sizes and 95% confidence intervals were reported. Qualitative analyses, based on Centre for Evidence Based Medicine levels of evidence, were conducted for function and disability. Eleven studies were included in the review. Interventions included general physiotherapy, cervical traction, manual therapy, exercise therapy, and behavioural change approaches. There was inconclusive evidence for the effectiveness of non-invasive management of cervicobrachial pain. Potential benefits were indicated in the provision of manual therapy and exercise and behavioural change approaches to reduce pain. General physiotherapy and traction were no more effective than comparators in reducing pain (level A evidence). Effects of non-invasive management on function and disability were mixed. Future studies should identify which sub-groups of cervicobrachial pain respond to specific interventions.
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Retrospective cohort. To describe population-based trends and variations in surgery for degenerative changes of the cervical spine among Medicare beneficiaries, 1992 to 2005. Degenerative changes of the cervical spine are seen radiographically in over half of the population aged 55 years or greater, and rates of cervical spine surgery have increased over time. Prior studies examined anterior cervical discectomy and fusion procedures in the general population up to 1999, and showed regional variations in care, with the highest rates in the South. The purpose of this study is to explore population-based trends and variations in surgery for degenerative changes of the cervical spine in the elderly. From 1992 to 2005, hospital admissions associated with surgery for degenerative changes of the cervical spine were selected from Medicare Part A using ICD9 CM codes. We excluded beneficiaries under 65 years of age, in a capitated health plan, or enrolled for Social Security Disability Income. Diagnosis and type of surgery were defined using ICD9 CM codes. Rates were directly adjusted to age, sex, and race of 2005 Medicare beneficiaries. Of 156,820 qualifying admissions, 52% were men, 88% were white, and 41% were aged 65 to 69 years. The most common primary diagnosis and procedure were cervical spondylosis with myelopathy (36%) and fusion (70%); of the fusions, 58% were anterior. Rates of cervical fusions rose from 1992 to 2005 even after adjustment for age, sex, and race (14.7 to 45 cervical fusions/100,000 beneficiaries). Rates of cervical fusions varied by geographic location, with the highest rates in the Northwest and South Central regions. In 2005, the highest rate of cervical fusions was 140/100,000 beneficiaries in Idaho, compared with 4/100,000 beneficiaries in Washington, DC. In the elderly, adjusted rates of cervical spine fusions rose 206% from 1992 to 2005. Marked geographic variation was noted. Future studies should evaluate the efficacy and complications associated with these procedures in the elderly, and better define surgical indications and patient outcome.
Article
Best evidence synthesis. To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders. No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade. We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis. Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus. Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies.
Article
A prospective, concurrently controlled, randomized, multicenter trial of an anterior Bagby and Kuslich cervical fusion cage (BAK/C; Sulzer Spine-Tech, Minneapolis, MN) for treatment of degenerative disc disease of the cervical spine. To report clinical results with maximum 24-month follow-up of fusions performed with the BAK/C fusion cage. Threaded lumbar cages have been used during the past decade as a safe and effective surgical solution for chronic disabling low back pain. Threaded cages have now been developed for use in anterior cervical interbody fusions to obviate the need for allografts or autogenous bone grafting procedures while providing initial stability during the fusion process. Patients with symptomatic cervical discogenic radiculopathy were treated with either anterior cervical discectomy with uninstrumented bone-only fusion (ACDF) or BAK/C fusion cage(s). Independent radiographic assessment of fusion was made and patient-based outcome was assessed by visual analog pain scale and a Short Form (SF)-36 Health Status Questionnaire. Data analysis included 344 patients at 1 year and 180 at 2 years. When the two cage groups (hydroxya, patite-coated or noncoated) were compared with the ACDF group, similar outcomes were noted for duration of surgery, hospital stay, improvements in neck pain and radicular pain in the affected limb, improvements in the SF-36 Physical Component subscale and Mental Component subscale, and the patients' perception of overall surgical outcome. Symptom improvements were maintained at 2 years. A greater percentage of patients with ACDF needed an iliac crest bone harvest than did BAK/C patients (67% vs.- 3%). Successful fusion for one-level procedures at 12 months was 97.9% for the BAK/C groups and 89.7% for the ACDF group (P < 0.05). The complication rate for the ACDF group was 20.4% compared with an overall complication rate of 11.8% with BAK/C. There was no difference in complications that necessitated a second operative procedure. These results demonstrate that outcomes after a cervical fusion procedure with a threaded cage are the same as those of a conventional uninstrumented bone-only anterior discectomy and fusion with a low risk of complications and rare need for autogenous bone graft harvest.
Article
Recent findings that spinal manual therapy (SMT) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain (dPAG). In addition to hypoalgesic and sympathoexcitatory effects, stimulation of the dPAG in animals has been shown to have a facilitatory effect on motor activity. This study sought to further investigate the proposal regarding SMT and the PAG by including a test of motor function in addition to the variables previously investigated. Using a condition randomised, placebo-controlled, double blind, repeated measures design, 30 subjects with mid to lower cervical spine pain of insidious onset participated in the study. The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment (P=0.0001) and decreased resting visual analogue scale scores (P=0.049). The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance (P<0.002) and a decrease in skin temperature (P=<0.02). There was a decrease in superficial neck flexor muscle activity (P<0.0002) at the lower levels of a staged cranio-cervical flexion test. This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors. The combination of all findings would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG.
Article
Mechanical neck pain is a common occurrence in the general population resulting in a considerable economic burden. Often physical therapists will incorporate manual therapies directed at the cervical spine including joint mobilization and manipulation into the management of patients with cervical pain. Although the effectiveness of mobilization and manipulation of the cervical spine has been well documented, the small inherent risks associated with these techniques has led clinicians to frequently utilize manipulation directed at the thoracic spine in this patient population. It is hypothesized that thoracic spine manipulation may elicit similar therapeutic benefits as cervical spine manipulation while minimizing the magnitude of risk associated with the cervical technique. The purpose of this randomized clinical trial was to investigate the immediate effects of thoracic spine manipulation on perceived pain levels in patients presenting with neck pain. The results suggest that thoracic spine manipulation results in immediate analgesic effects in patients with mechanical neck pain. Further studies are needed to determine the effects of thoracic spine manipulation in patients with neck pain on long-term outcomes including function and disability.