During the last 10
years there has been a significant increase in the number of lumbar spine fusions (LSF) [1
]. The most common reasons for LSF are isthmic or degenerative spondylolisthesis, degenerative disc disease, and spinal stenosis [2
]. In adult patients with lumbar isthmic or degenerative spondylolisthesis LSF has been reported to reduce symptoms [3
]. However, the overall disability of patients after LSF may be high [5
] and even 25% of patients rated the overall outcome as unchanged or worse in a 2-year follow-up study [3
]. Most of the previous studies on LSF have evaluated the surgical procedure itself or compared conservative treatment to operative treatment. Less information is available on long-term exercise programs for patients after LSF surgery.
The effectiveness of rehabilitation after LSF has only been evaluated in four studies [6
]. In these studies, the timing of the intervention has differed. In the studies of Nielsen et al. [8
], prehabilitation started 6 to 8
weeks before surgery and continued during hospitalization. Abbott et al. [6
] evaluated the effectiveness of psychomotor therapy implemented during the first 12 postoperative weeks. A Danish study [7
] compared three different postoperative rehabilitation programs lasting between 12 and 20 postoperative weeks.
Exercise was an essential component of the rehabilitation protocols in all the LSF rehabilitation studies; however the guidance and exercise methods used were different. In the studies of Nielsen et al. and Christensen et al. [7
], exercise programs included muscle endurance and strength training for the back and abdominal muscles, and cardiovascular conditioning. In the study of Abbott et al. [6
], the exercise program consisted of motor relearning training of the transversus abdominis and multifidus, with cognitive and behavioral elements also integrated into the program. The results of these studies indicate that exercise may improve the outcome of LSF.
Typically, patients with lumbar isthmic or degenerative spondylolisthesis undergoing LSF have suffered low back pain for years and therefore may exhibit changes in the function [10
] and structure of their trunk muscles [11
], and in their cardiorespiratory condition [12
]. LSF itself causes changes in the biomechanics of the lumbar spine, which may also accelerate degenerative changes in the adjacent segments [13
] and cause muscle atrophy, leading to fatty infiltration of the lumbar muscles, especially in the multifidus[14
]. As a possible consequence of these changes, low trunk muscle strength levels in patients after lumbar fusion have been reported [17
The primary goals of the post-operative rehabilitation program are to control pain, decrease disability, restore back function, improve health related fitness and learn to use the low back during the healing process. Although the existing evidence supports the use of exercise in the rehabilitation of LSF patients, there is no consensus on the content of an exercise rehabilitation program after LSF. In addition, the durations of earlier interventions have been too short to achieve long-term changes in back function. Thus, there is a need to develop and test multifaceted rehabilitation programs to improve both back-specific and overall outcome after LSF. In contrast with previous exercise interventions for LSF patients, this study is novel in its development of a fusion-specific training program that takes into account changes in the biomechanics of the spine.
The main study questions are:
· Is combined back-specific and aerobic training more effective in decreasing back pain and disability than conventional instructions in postoperative rehabilitation?
· What are the effects of surgery and training on trunk muscle strength and mobility of the spine?
· What is the effect of fear of movement on post-operative exercise adherence, physical activity, pain and disability?