Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis

Abstract

Purpose To evaluate the efectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis. Methods Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the efect of rehabilitation (unimodal or multimodal). The estimated efect size was calculated for interventions with homogeneous content using a random-efects model. Certainty of evidence was assessed by GRADE. Results In total, 18 RCTs, including 1402 unique patients, compared specifc rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more efective for reducing disability and pain than usual care (standardized mean diference [95% CI]: −0.41 [−0.71; −0.10] and −0.36 [−0.65; −0.08], four and fve studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more efective in reducing disability and pain-related fear than exercise therapy alone (−0.31 [−0.49; −0.13] and −0.64 [−1.11; −0.17], six and four studies, respectively). Efects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies). Conclusion There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are efective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefts over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the efectiveness of rehabilitation strategies in the long term and for work-related outcomes