Clinical trial of postoperative dynamic back exercises after first lumbar discectomy. Rehabilitation after surgery for lumbar disc herniation: results of a randomized clinical trial. Economic evaluation of a behavioral-graded activity program compared to physical therapy for patients following lumbar disc surgery. The effectiveness of exercise programmes after lumbar disc surgery: a randomized controlled study. Can exercise therapy improve the outcome of microdiscectomy? Early aggressive exercise for postoperative rehabilitation after discectomy. A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy. Early active training after lumbar discectomy. A prospective, randomized, and controlled study. Intensive dynamic back exercises with or without hyperextension in chronic back pain after surgery for lumbar disc protrusion. A clinical trial. Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscectomy. Supervised endurance exercise training compared to home training after first lumbar diskectomy: a clinical trial. Effects of home strength training and stretching versus stretching alone after lumbar disk surgery: a randomized study with a 1-year follow-up. Return to work after surgery for lumbar disc herniation. A rehabilitation-oriented approach in insurance medicine. Randomized controlled trial of neural mobilization after spinal surgery.
Ninety-six patients who had undergone first-time discectomy for herniated lumbar intervertebral discs were consecutively randomized to two physical rehabilitation programs: a program of high-intensity, dynamic back extension and abdominal exercises with occurrence of low back pain being the limiting factor or a traditional program of mild, generally mobility-improving exercises within pain limits. Both groups underwent 14 hours of treatment during a 6-week period 5 weeks after surgery. At 26 weeks' follow-up, results indicated that patients who did the high-intensity exercises experienced greater success with regard to the patient disability-index and work capabilities. After 1 year, a trend that favored the use of intensive exercises could be observed. No differences were found in pain or objective measurements. A rehabilitation program of intensive exercises with occurrence of back pain being the limiting factor appears to increase patient behavioral support, resulting in work capacity improvements and patient self-rated disability levels. The results indicate that a 6-wk, 14-hr postoperative rehabilitation program is inadequate if objective postoperative deficit improvements are the desired goal. The aim of this prospective study was to examine the one-year postoperative results in patients operated on for lumbar disc herniation randomized in two groups: one with comprehensive rehabilitation and the other taken care of by normal care facilities. A total of 212 patients without any previous spinal operations comprised the final study group. The physiatrist, the surgeon, the social worker, and the psychologist performed the handicap evaluation according to the occupation handicap scales of the WHO. The handicap was evaluated for two phases: before the onset of acute sciatica leading to operation and one year after operation. No significant differences in handicap distribution between the intervention and normal care groups were seen. The postoperative handicap correlated highly significantly with preoperative handicap for both groups. More than half (57%) of all the patients returned to work within two months of the operation. The amount of sick leaves did not differ significantly between the intervention and normal care groups. A total of 15 persons (7%) retired during the postoperative year. An economic evaluation was conducted alongside a randomized controlled trial.
                Little is known about the effectiveness of cognitive-behavioral treatment options for patients following lumbar disc surgery. If the knowledge available was supported by an economic evaluation, the information could then be used to make recommendations for the implementation of cognitive-behavioral treatment in the routine of rehabilitation following lumbar disc surgery.
                To examine the cost-effectiveness of a behavioral-graded activity program, which is an operant treatment, compared to usual care as delivered by a physical therapist for patients following first-time lumbar disc surgery.
                For the economic evaluation, a societal viewpoint was applied. The primary outcome measures (measured at the 12-month follow-up) were global perceived effect and functional status. To evaluate the economic consequences of the treatments, direct health care and non-health care costs were considered, as well as indirect costs.
                The clinical outcomes showed no relevant differences between behavioral-graded activity (n = 52) and UC (n = 53). Treatment costs were almost identical in the two intervention groups. The difference in direct health care costs was, although not statistically significant, 264 EURO [95% CI: -3-525] higher in behavioral-graded activity than in usual care per patient-year. It was mainly the excess cost of visiting the physiotherapist in the behavioral-graded activity group that accounted for this difference. The difference in direct non-health care costs, although not statistically significant, was 388 EURO [95% CI: -217; 992] lower in the usual care group due to unpaid help by friends or family. Consequently, although again not statistically significant, the total direct costs in behavioral-graded activity are 639 EURO [95% CI: -91; 1368] higher than in usual care. For the indirect costs, there was a statistically significant difference, behavioral-graded activity being more expensive. The sensitivity analysis showed that these results are fairly robust.
                This study concludes that there are no differences between the two treatment conditions on any of the clinical outcome measures but that behavioral-graded activity is associated with higher costs. Consequently, there is no reason for the implementation of behavioral-graded activity as the standard treatment for patients following lumbar disc surgery. To compare two different exercise programmes versus a control group, after lumbar disc surgery.
                A prospective, single-blind, randomized controlled study.
                Outpatient clinic of Istanbul Faculty of Medicine, Department of Physical Medicine and Rehabilitation.
                Sixty patients diagnosed as having single level lumbar disc herniation with clinical examination and MRI evaluation and who had undergone lumbar discectomy (post-operative first month) at a single level. Patients with serious pathologies involving the cardiac and respiratory systems that could prevent them from doing exercises were excluded. Intervention: The patients were randomly split into three groups. The first group received an intensive exercise programme and back school education while the second group received a home exercise programme and back school education. The third group was defined as the control group and did not receive education or exercise.
                The patients were evaluated at the beginning and end of the treatment with clinical parameters, pain levels, endurance tests and weight-lifting tests, modified Oswestry Disability Index, Beck Depression Inventory, Low Back Pain Rating Scale and return to work.
                The groups doing exercises experienced a decrease in the severity of pain and disability, also functional parameters showed better improvement than the control group. The intensive exercise programme was better than the home exercise programme.
                It seems that intensive exercise is more effective in reduction of pain and disability, but whether it is cost-effective is not clear. A prospective randomized controlled trial of exercise therapy in patients who underwent microdiscectomy for prolapsed lumbar intervertebral disc. Results of a pilot study are presented.
                To determine the effects of a postoperative exercise program on pain, disability, psychological status, and spinal function.
                Microdiscectomy is often used successfully to treat prolapsed lumbar intervertebral disc. However, some patients do not have a good outcome and many continue to have low back pain. The reasons for this are unclear but impairment of back muscle function due to months of inactivity before surgery may be a contributing factor. A postoperative exercise program may improve outcome in such patients.
                Twenty patients who underwent lumbar microdiscectomy were randomized into EXERCISE and CONTROL groups. After surgery, all patients received normal postoperative care that included advice from a physiotherapist about exercise and a return to normal activities. Six weeks after surgery, patients in the EXERCISE group undertook a 4-week exercise program that concentrated on improving strength and endurance of the back and abdominal muscles and mobility of the spine and hips. Assessments of spinal function were performed in all patients during the week before surgery and at 6, 10, 26, and 52 weeks after. The assessment included measures of posture, hip and lumbar mobility, back muscle endurance capacity and electromyographic measures of back muscle fatigue. On each occasion, patients completed questionnaires inquiring about pain, disability and psychological status.
                Surgery improved pain, disability, back muscle endurance capacity and hip and lumbar mobility in both groups of patients. After the exercise program, the EXERCISE group showed further improvements in these measures and also in electromyographic measures of back muscle fatigability. All these improvements were maintained 12 months after surgery. The only further improvement showed by the CONTROL group between 6 and 52 weeks was an increase in back muscle endurance capacity.
                A 4-week postoperative exercise program can improve pain, disability, and spinal function inpatients who undergo microdiscectomy. [Key words: electromyogram median frequency, exercise therapy, intervertebral disc prolapse, microdiscectomy, randomized controlled trial, spinal function. A randomized clinical trial of postoperative medical exercise therapy in patients after operation for lumbar disc herniation with blind assessment of clinical outcomes.
                To assess the effect of an early regimen of vigorous medical exercise compared with an ordinary care program.
                
                Patients offered an operation for lumbar disc herniation were consecutively randomized to a training group or to a control group. The training consisted of an 8-week active rehabilitation program including a regimen of vigorous lumbar stabilizing exercises. The control subjects participated in a mild program of 2 to 3 back exercises at home, after relaxing and resting their backs for 2 months after the surgery. The outcomes were evaluated 6 and 12 months after the operation. The results are based on intention-to-treat analyses.
                Sixty-three of 65 eligible patients agreed to participate in the trial. Fifty-eight and 53 patients attended for evaluation at 6 and 12 months, respectively. There was a significantly larger improvement in the mean Roland's disability index (from 8.9 to 5.4 [P = 0.02] at 6 months and from 8. 7 to 5.3 [P = 0.03] at 12 months) and in reported pain (from 3.7 to 2.0 [P = 0.04] at 6 months and from 3.2 to 1.8 [P = 0.09] at 12 months) in the training group. A significantly (P = 0.05) higher proportion of the training group reported that they participated in daily activities as usual. There were more patients in the training group who reported improvement in self-evaluated health after surgery at both 6 (P = 0.02) and at 12 months (P = 0.05). Finally, no differences in clinical end points were observed between the groups.
                Vigorous medical exercise therapy, started 4 weeks after surgery for lumbar disc herniation, reduced disability and pain after surgery. Because no differences in clinical end points were observed, there is hardly any danger associated with early and vigorous training after operation for disc herniation. The professional literature contains relatively few randomized-control studies that have assessed the efficacy of physical therapy approaches to the management of patients with chronic low back pain (CLBP). The purposes of this study were: 1) to investigate the effects of physical agents, joint manipulation, low-tech exercise, and high-tech exercise on objective measures of CLBP; 2) to track the length of CLBP relief; and 3) to determine treatment cost-effectiveness. Two-hundred-fifty subjects (68 females, 182 males; ages 34-51 years) with CLBP following an L5 laminectomy were randomly assigned into five separate groups for a treatment period of 8 weeks. Chronic low back pain status was measured by modified-modified Schober, Cybex Liftask, and Oswestry procedures. Results revealed that: 1) only low-tech and high-tech exercise produced significant improvements (p < .05) in CLBP, 2) the mean period of CLBP relief ranged from 1.6 weeks (control) to 91.4 weeks (low-tech exercise), and 3) low-tech exercise was most cost-effective. It was concluded that: 1) low-tech and high-tech exercise were the only effective treatments for CLBP, 2) low-tech exercise produced the longest period of CLBP relief, and 3) low-tech exercise was the most cost-effective form of treatment. Clinically, low-tech exercise may be the treatment method of choice for the effective management of chronic low back pain. A prospective, randomized, and controlled study was conducted.
                To evaluate two training programs, both of which started immediately after lumbar discectomy.
                In previous studies, patients began physiotherapy between 4 weeks and 60 months after surgery. No studies have been conducted to evaluate a physiotherapy program that begins immediately after surgery.
                Twenty-six patients were treated according to an early active training program. Twenty-six patients were treated with a traditional, less active training program (control group). All patients were examined immediately before and after surgery and 3, 6, 12, and 52 weeks after surgery by an unbiased observer. Two years after surgery, patients completed a questionnaire. Range of motion of the lumbar spine and straight leg raising were measured. pain intensity and location was measured by a visual analog scale. The duration of sick leave was documented.
                Six and 12 weeks after surgery, patients with dominating residual leg pain had significantly less intense pain in the early active training group than those in the control group (P < 0.05). Twelve weeks after surgery, range of motion of the lumbar spine was significantly more increased in the early active training group (P < 0.01). One year after surgery, there was no significant difference between the groups regarding the duration of sick leave, results in a positive straight leg raising, or pain intensity. Twenty-two (88%) patients in the early active training group and 16 (67%) in the control group were satisfied with the treatment outcome 2 years after surgery (P < 0.10).
                Patients rehabilitated according to the early active training program had a better short-term outcome of objective values. At 2 years' follow-up, more patients were satisfied with the result of the operation. The early active treatment program is recommended. Sixty-two patients with chronic low back pain occurring 14-60 months after undergoing discectomy for the first time were randomized to two physical treatment groups: 24 sessions of intensive dynamic back exercises with hyperextension or 24 sessions of intensive dynamic back exercises without hyperextension. At the conclusion of therapy and at one-year follow-up, no difference was seen between the randomized groups, with regard to the combined assessments of pain, disability and objective measurements. A difference for back exercises without hyperextension to be superior to the other treatment regimen was statistically significant at the three-month follow-up. In the patient's qualitative assessment of treatment outcome there were seen no significant differences between back exercises with or without hyperextension. There was a similar and significant improvement of the isometric endurance of back muscles in both groups, but the flexibility of the spine was significantly improved only in the group using hyperextension exercises. The overall response rate of an earlier published investigation was reproduced. It is concluded that chronic back patients after first time discectomy may benefit from an intensive rehabilitation protocol including intensive exercises. The added use of hyperextension exercises does not confer any independent benefit. Furthermore, the training had to continue for more than 2-3 months before a statistical significant decrease in back pain was reported in the patient pain diary. The aim of this study was to determine the efficacy of dynamic lumbar stabilization exercises in patients with lumbar microdiscectomy.
                A prospective, randomized, controlled study.
                Forty-two patients who were diagnosed as having lumbar disc herniation and had been operated on using the microdiscectomy method were divided randomly into 3 groups.
                Dynamic lumbar stabilization exercises were set for the first group and a home exercise programme for the second. The third group given no exercises was considered as a control group. All patients were examined twice, once before the exercise programme and once 8 weeks later.
                Improvement in the first group was highly significant after the treatment (p < 0.0001). The second group improved significantly more in some parameters (pain, functional disability, lumbar Schober, progressive isoinertial lifting evaluation (neck), trunk endurance (flexion-extension)) than did the third group. The third group of patients showed some improvement in fingertip-floor distance, functional disability, modified lumbar Schober and left rotation in 8 weeks, but there were no significant improvements in the other parameters.
                Dynamic lumbar stabilization exercises are an efficient and useful technique in the rehabilitation of patients who have undergone microdiscectomy. They relieve pain, improve functional parameters and strengthen trunk, abdominal and low back muscles. We performed a randomised trial to evaluate if intensive supervised training of the back should be offered to all patients after a first lumbar diskectomy.
                Forty consecutive patients were, after a first lumbar diskectomy, randomly allocated to 2 groups undergoing "supervised training" twice a week for 3 months in an outpatient clinic or "home training" after 2 hours of instruction.
                The two rehabilitation models both showed a significant effect on spinal mobility, isokinetic trunk flexion strength, isokinetic trunk extension strength and daily function. These improvements were unchanged at follow up 3 months later. The pain score remained unchanged, however, throughout the trial in both groups. No differences in effect between the two rehabilitation models could be found for any of the assessed parameters. Thirteen patients did not complete the trial, including 9 from the supervised endurance trained group, mainly because of increased pain and reprolaps (n = 4). Four patients dropped out of the home trained group, only one because of increased pain. The differences in drop-out rate and training side effects were, however, not statistically significant.
                We conclude that it is not worthwhile to implement 3 months of supervised intensive endurance training as opposed to home training in all cases of first lumbar diskectomy, although a beneficial effect and better compliance might be found for a selected group of such patients. To assess the adherence to and effects of a 12-month combined strength and stretching home exercise regimen versus stretching alone, on patient outcome after lumbar disk surgery.
                Randomized controlled trial.
                Departments of physical medicine and rehabilitation and orthopedics at a Finnish hospital.
                Patients (N=126) were randomized into either a combined strength training and stretching group (STG, n=65) or a control group (CG, n=61).
                The STG was instructed to perform strength training and both the STG and CG were instructed in the same stretching and stabilization exercises for 12 months.
                Pain on the visual analog scale (VAS), the Oswestry and the Million disability indexes, isometric and dynamic trunk muscle strength, mobility in the lumbar spine, and straight-leg raising were measured.
                The trial was completed by 71% and 77% of the patients from the STG and the CG, respectively. The mean strength training frequency decreased from 1.5 to 0.6 times a week in the STG during the intervention. The mean stretching frequency decreased from 3.7 to 1.6 times a week in both groups. Median back and leg pain varied between 17 and 23 mm (VAS), and the Million and Oswestry indices varied between 14 and 23 points 2 months postoperatively. No statistically significant changes took place in these outcome measures during the 12-month follow-up in both groups. The changes in isometric trunk extension favored the STG ( P =.016) during the first 2 months. However, during the whole 12-month training period, both dynamic and isometric back extension and flexion strength, as well as mobility of the spine and repetitive squat-test results, improved significantly in both groups, and no differences were found in any of the physical function parameters between the STG and CG.
                At the 12-month follow-up, no statistically significant changes were found in the physical function, pain, or disability measures between the groups. In the STG, training adherence with regard to training frequency and intensity remained too low to lead to specific training-induced adaptations in the neuromuscular system. Progressive loading, supervision of training, and psychosocial support is needed in long-term rehabilitation programs to maintain patient motivation. An intervention study by the medical advisers of a social security sickness fund on a mandatorily insured patient population after open discectomy for herniated lumbar intervertebral disc. The medical advisers were randomized into two groups: a control group (n = 30) and an intervention group (n = 30).
                To compare a rehabilitation-oriented approach in insurance medicine focused primarily on early mobilization and early resumption of professional activities with the usual claim-based practice.
                This study included 710 patients, with a mean age of 39.2 years, who underwent surgery for herniated lumbar disc.
                Medical advisers in the rehabilitation-oriented group examined the patients monthly, starting at 6 weeks after the surgical intervention. They used a newly developed protocol to motivate the patients and treating physicians toward social and professional reintegration.
                At 52 weeks, 10.1% of the patients guided by medical advisers from the rehabilitation-oriented group had not resumed work in contrast to 18.1% of the patients in the control group. It was statistically proven that this effect also holds during the follow-up period.
                A rehabilitation-oriented approach by the medical advisers of social security can increase the probability of a return to work for patients after lumbar disc herniation surgery. Randomized controlled trial with 12-month follow-up.
                To determine whether the addition of neural mobilization to standard postoperative care improved the outcome of lumbar spinal surgery.
                It has been suggested that neural mobilization should be performed after spinal surgery to prevent nerve root adhesions and improve outcome. However, to date, there is no convincing evidence of the value of neural mobilization.
                Eighty-one patients undergoing lumbar discectomy, fusion, or laminectomy at a private hospital in Sydney were randomly allocated to standard postoperative care or standard care plus neural mobilization. Neural mobilization included passive movements and active exercises designed to mobilize the lumbosacral nerve roots and sciatic tract. Primary outcome measures were global perceived effect measured on a 7-point scale, pain measured using visual analogue scales and the McGill Pain Questionnaire, and disability measured with the Quebec Disability Scale.
                All patients received the treatment as allocated with 12-month follow-up data available for 76 patients (94% of those randomized). There were no statistically significant or clinically significant benefits provided by the neural mobilization treatment for any outcome.
                The neural mobilization protocol evaluated in this study did not provide an additional benefit to standard postoperative care for patients undergoing spinal surgery. The authors advocate that this protocol not be used in clinical practice.
Exercise programs starting four to six weeks post-surgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the re-operation rate after first-time lumbar surgery.