Can Spinal Surgery Be Prevented by Aggressive Strengthening Exercises? A Prospective Study of Cervical and Lumbar Patients.

Nelson BW, Carpenter DM, Dreisinger TE, et al (Physicians Neck and Back Clinic, Roseville, Minn), Arch Phys Med Rehabil. 1999;80:20-25.

According to the authors, the number of surgical procedures for spinal disorders continues to rise even though there have been numerous less-than-optimal outcomes. Partly because of surgery's limited success and expense, the effectiveness and outcomes of noninvasive treatment strategies are being studied. The authors of this study evaluated the short-term effect of an aggressive strengthening program on patients who had been previously recommended for surgery.

Over a 2 1/2-year period, consecutive patients referred to the authors' clinic were considered for the study if they (1) had a physician's recommendation for lumbar or cervical surgery, (2) had no medical condition that prevented exercise, and (3) were willing to participate in the outpatient training program, which took approximately 10 weeks. Of the 651 patients referred to the clinic during the study period, 62 met these criteria, and 60 patients began the program. The average patient age was 42 years old, and the average duration of symptoms was 28 months.

At the initiation of the strengthening program, subjects performed 20 repetitions of a maximum dynamic endurance test to the following muscle groups: lumbar extensors, cervical extensors, torso rotators, and cervical rotators. The strengthening program consisted of aerobic exercise, progressive resistive exercises on equipment that isolated the lumbar and cervical spine in both the sagittal and transverse planes, and strength training of other major muscle groups. The intensity of the weight load was adjusted periodically to allow a maximum of approximately 20 repetitions during each workout. According to the authors, the training was vigorous and did not stop because of pain exacerbation. Instead of stopping the training, a physician saw the patient and, in the absence of clinical evidence of significant deterioration, reassured the patient and continued the treatment.

The primary outcome of interest was whether or not the patients underwent spinal surgery after participating in the program. Two additional outcomes were reported for subjects who completed the program: (1) change in dynamic endurance (defined as the amount of weight that could be lifted for approximately 20 repetitions before fatigue) and (2) a response-to-treatment grade (rated as excellent, good, fair, or poor according to a 10-point system).

Of the 60 subjects who began the program, 46 completed it (28 men and 18 women), and 38 were located by phone for follow-up. The average follow-up was 16.2 months (range = 12-30 months) after the patient was last seen in the clinic. Of the 38 subjects contacted, only 3 had undergone surgery.

With regard to the secondary outcome measures, there was a significant increase in dynamic endurance in all motions tested from initiation to completion of the program. In addition, response-to-treatment grades were as follows: 17 excellent, 14 good, 4 fair, and 3 poor. The authors discussed numerous limitations of their study. For example, patients were not randomized into a treatment group, and the study had no control group. Furthermore, the grading of response to treatment was not determined by a rater who was blinded to the subject data. The authors also mentioned that the patients in this study may have been more motivated to avoid surgery, and those that did avoid surgery may have been miserable because they did.

In spite of the limitations, the authors believed that the study is valuable because it shows that a large number of surgical candidates can avoid surgery over an extended period with minimal complications. In addition, the authors said that the average cost of the program ($1,950) was considerably less than the average cost of spinal surgery (eg, $168,000 for lumbar fusion in a workers' compensation case).

Gaetano Lombardo, PT, OCS Long Island University Brooklyn, NY