Janssen ERC, Punt IM, Clemens MJ, et al. Current Prehabilitation Programs Do Not Improve the Postoperative Outcomes of Patients Scheduled for Lumbar Spine Surgery: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2021 Mar;51(3):103-114. doi: 10.2519/jospt.2021.9748. Epub 2020 Dec 25. (Systematic review)

OBJECTIVE: To assess the effectiveness of prehabilitation in patients with degenerative disorders of the lumbar spine who are scheduled for spine surgery.

DESIGN: Intervention systematic review with meta-analysis.

LITERATURE SEARCH: Seven electronic databases were systematically searched for randomized controlled trials or propensity-matched cohorts.

STUDY SELECTION CRITERIA: Studies that measured the effect of prehabilitation interventions (ie, exercise therapy and cognitive behavioral therapy [CBT]) on physical functioning, pain, complications, adverse events related to prehabilitation, health-related quality of life, psychological outcomes, length of hospital stay, use of analgesics, and return to work were included.

DATA SYNTHESIS: Data were extracted at baseline (preoperatively) and at short-term (6 weeks or less), medium-term (greater than 6 weeks and up to 6 months), and long-term (greater than 6 months) follow-ups. Pooled effects were analyzed as mean differences and 95% confidence intervals (CIs). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS: Cognitive behavioral therapy interventions were no more effective than usual care for all outcomes. Pooled effect sizes were -2.0 (95% CI: -4.4, 0.4) for physical functioning, -1.9 (95% CI: -5.2, 1.4) for back pain, and -0.4 (95% CI: -4.1, 0.4) for leg pain. Certainty of evidence for CBT ranged from very low to low. Only 1 study focused on exercise therapy and found a positive effect on short-term outcomes.

CONCLUSION: There was very low-certainty to low-certainty evidence of no additional effect of CBT interventions on outcomes in patients scheduled for lumbar surgery. Existing evidence was too limited to draw conclusions about the effects of exercise therapy. J Orthop Sports Phys Ther 2021;51(3):103-114. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9748.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 4 / 7
Comments from MORE raters

Physician rater

As an orthopaedic surgeon, I find the results of this meta-analysis are still inconclusive due to the low-quality of evidence from most of the selected studies (from the inability to blind the intervention). Although the trend of the majority showed better outcomes in the intervention group, it did not show statistical significance.

Physician rater

The topic of this paper does not belong to psychiatry.

Rehab Clinician (OT/PT) rater

Although the title is accurate, the main findings of this study were only in relation to cognitive behaviour therapy. In relation to exercise, the findings were, "Existing evidence was too limited to draw conclusions about the effects of exercise therapy".

Rehab Clinician (OT/PT) rater

Despite the small numbers and other limitations that the authors describe, it is useful to know that pre-operative rehabilitation programs cannot be recommended. It will save patient's time and expense, and save the PT and the patient frustration over poor outcomes.

Rehab Clinician (OT/PT) rater

This article demonstrates the paucity of current evidence in this area. I think the conclusions are very difficult to make as the various studies to not particularly describe the current topic. Having said this, in practice, it would not be uncommon to further improve patients who are already awaiting surgery as changes to their perception of pain and expectations are complex due to the biomedical framework that surgery proposes.

Rehab Clinician (OT/PT) rater

This was a well-done and robust systematic review and meta-analysis. However, as the authors point out, the number of studies included likely yielded insufficient evidence to arrive at conclusive findings. Nonetheless, given the clear rigor and high quality of this study, the conclusions drawn, limited as they may be, can be considered highly reliable. The results of this study may provide useful information to clinicians, clients, and payors alike.
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