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Physical Therapy After Lumbar Spinal Fusion is Necessary to Optimize Patient Outcomes.

Lumbar fusion procedures have dramatically increased in number over the last 2 decades with epidemiologic studies citing a 356% increase from 1993 to 2001 and doubling from 1999 to 2011.1,2 Costs associated with these procedures have also increased significantly. In light of these increasing costs, postoperative physical therapy has garnered appropriate scrutiny with regard to its necessity following lumbar fusion. Rehabilitation regimens remain commonplace but are not often uniform and a relative scarcity of high-level evidence exists to guide treatment. However, the available research favors formal postoperative rehabilitation to improve strength, range of motion, cardiovascular endurance, and patient education,3 and we support its routine use following lumbar spinal fusion. Instrumented lumbar spinal fusion provides a stable construct that allows early patient mobilization to occur safely. Unfortunately, because of the pain and anxiety that often accompany surgical intervention, many patients are hesitant to move following their procedure. Physical therapy plays an important role both in the immediate inhospital postoperative phase as well as the acute rehabilitation period. Therapy protocols encourage early physical activity, providing reassurance, teaching transfer techniques, and promoting neutral spine control exercises to assist patients in their recovery. Typically, rehabilitation following lumbar fusion surgery is divided into 3 phases. The first phase begins in the hospital and focuses on basic mobilization and weight bearing activities such as sitting, transfers, and ambulation. The second phase involves outpatient or home-based rehabilitation exercises which emphasize conditioning and strengthening of the core musculature. Finally, the third phase is designed around specific return-to-work rehabilitative interventions. Despite the recognized value of postoperative physical therapy in lumbar fusion surgery, no “gold standard” rehabilitation protocol has been defined in the literature. Perhaps not surprisingly, there is a wide divergence among practitioners in the types of rehabilitative services used and the timing of such treatment relative to surgery.3 Preoperative and postoperative cardiovascular exercise has been shown to decrease length of stay and improve patient-reported outcome scores postoperatively.4 Ambulation is the most common form of cardiovascular exercise utilized, but stationary bicycle and aquatic therapy have roles as well. These forms of generalized aerobic exercise have been shown to decrease pain and increase function at least in the short term after surgery, with a randomized trial with regard to early rehabilitation showing statistically and clinically significant improvements in Oswestry Disability Index (ODI) scores for patients engaged in early rehabilitation protocols.5 There has also been a movement to address psychosocial factors in postfusion rehabilitative regimens as a means to address nonmedical influencers of patient outcomes. Some European studies have touted the promising results seen when a psychosocial approach is included in the postfusion rehabilitation regimen such as with the Christensen “Back Café” model.6 By supplementing physical measures with multidisciplinary biopsychosocial modalities, patient outcomes are improved across multiple domains. It is known that lumbar fusion has a detrimental effect on the form and function of the extensor musculature of the lumbar spine.7,8 Relevantly, this deterioration of the paraspinal musculature has been correlated with worse patient-reported outcomes following surgery.9 Physical therapy, specifically focusing on cocontraction of the deep abdominal and multifidus muscles, has been shown to result in paraspinal strength gains in prospective investigation and correlated to lower ODI scores.10,11 For these reasons, we find therapy focusing on a patient’s core and paraspinal musculature a necessary part of optimal patient recovery. Received for publication August 9, 2018; accepted August 15, 2018. From the *Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA; and †Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Washington, DC. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors declare no conflict of interest. Reprints: Patrick Morrissey, MD, Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134 (e-mail: Patrick.b.morrissey@gmail.com). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. CONTROVERSIES IN SPINE SURGERY