Tegner H, Rolving N, Henriksen M, et al. The Effect of Graded Activity and Pain Education After Lumbar Spinal Fusion on Sedentary Behavior 3 and 12 Months Postsurgery: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2024 Apr 27:S0003-9993(24)00942-0. doi: 10.1016/j.apmr.2024.04.005. (Original study)

OBJECTIVES: To examine the effect of an early postsurgical intervention consisting of graded activity and pain education (GAPE) in patients with chronic low back pain (CLBP) undergoing lumbar spinal fusion (LSF) on sedentary behavior, disability, pain, fear of movement, self-efficacy for exercise and health-related quality of life (HRQoL) at 3-, 6-, and 12 months follow-up.

DESIGN: A parallel-group, observer-blinded randomized controlled trial.

SETTING: Department of Occupational- and Physiotherapy and the Centre for Rheumatology and Spine Diseases, Rigshospitalet, Denmark.

PARTICIPANTS: In total, 144 participants undergoing an LSF for CLBP were randomly assigned to an intervention or a control group.

INTERVENTIONS: The intervention group received 9 sessions of GAPE, based on principles of operant conditioning.

MAIN OUTCOME MEASURES: The primary outcome was reduction in time spent in sedentary behavior, measured by an accelerometer at 3 months. The secondary outcomes were reduction in time spent in sedentary behavior at 12 months and changes from baseline to 3-, 6-, and 12 months on disability, pain, fear of movement, self-efficacy for exercise, and HRQoL.

RESULTS: No difference in changes in sedentary behavior between groups was found 3 months after surgery. At 12 months after surgery, there was a significant difference between groups (mean difference: -25.4 min/d (95% confidence interval -49.1 to -1.7)) in favor of the intervention group.

CONCLUSIONS: Compared with usual care, GAPE had no effect on short-term changes in sedentary behavior but GAPE had a statistical, but possibly not clinical significant effect on sedentary behavior 12 months after LSF. Further, the behavioral intervention was safe to perform.

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

Physician rater

This single-center trial found no significant short-term (3 months) effect of the cognitive-behavioral approach (Graded Activity and Pain Education - GAPE) on reducing sedentary behavior after lumbar spinal fusion surgery compared with usual care. It did find a significant, but possibly not clinically significant, effect at longer-term (12 months). This suggests that content and delivery of the GAPE intervention may not have been strong enough to effectively change fear-avoidance beliefs in this population and that changes in sedentary time are influenced by complex factors.

Rehab Clinician (OT/PT) rater

As a physical therapist, I found the study's results consistent with previous studies showing positive benefits of graded activity and pain education using a multidisciplinary approach for patients experiencing chronic pain. It was clinically reassuring that the benefits from these recommended interventions were also successful post lumbar surgery. However, the usual care group was nothing more than a control group; the authors should have used that term. Usual care group was not in-person but relied on a less than favorable education mode using synchronous audio telehealth. In addition, the intervention group received more visits compared to usual care, which may have also biased results. These limitations were not addressed by the authors. Overall the study was relevant but most clinicians who specialize in chronic pain management already know this.
Comments from PAIN+ CPN subscribers

Prof. Mike Poling (6/25/2024 8:29 AM)

This is wildly uncontrolled. The intervention is very much dependent on content and, MOST importantly, delivery. As a general rune, healthcare professionals are very poor at patient education across the board. The most likely reason for failure is the educator.