Early Active Training After Lumbar Discectomy: A Prospective, Randomized, and Controlled Study.

Kjellby-Wendt G, Styf J (Department of Orthopaedics, Sahlgrenska University Hospital, Ostra, Gothenburg, Sweden), Spine. 1998;23:2345-2351.

The authors studied 2 home programs of individualized training provided by physical therapists, which began immediately after lumbar discectomy. Sixty consecutive patients were randomized into 2 treatment groups; 8 subjects did not complete the study for a variety of reasons. Twenty-six subjects completed an early active training (EAT) program, and a control group of 26 subjects completed a traditional, less-active training program. The researchers designed the training programs as home programs. The inclusion criterion was neuromuscular dysfunction resulting from lumbar disk herniation in patients (age range = 16-70 years) who had not responded to nonsurgical treatment. The mean ages of the EAT group and the control group were 41 years and 39 years, respectively. An observer who had no knowledge of treatment group assignment examined the subjects in each group before surgery, within a week after surgery, and then at 3, 6, 12, and 52 weeks after surgery.

The physical examination included measurement of the range of motion of the lumbar spine using a kyphometer, a straight-leg-raising test using a goniometer, pain intensity measured on a 10-cm visual analog scale, determining the location of pain using the subjects' pain drawings, and rating the relative contribution of leg and back pain on a scale. Duration of sick leave after surgery was determined by the orthopedic surgeon who performed the operation and who did not know the type of physical intervention received. A questionnaire measuring adherence to the exercises was administered by the physical therapist at the follow-up appointments. Two years after surgery, subjects completed a questionnaire on residual sciatica, back pain, and their satisfaction with the results of the surgery.

All subjects underwent lumbar microdiscectomy without use of the microscope. The levels of disk herniation were similarly distributed in each group. The primary differences between the treatment programs for the EAT and control group were (1) the EAT program included exercises to increase range of motion of the trunk and the legs; (2) the strengthening exercises in the EAT group focused on strengthening the trunk extensors rather than the thigh and abdominal muscles; (3) a majority of the exercises in the EAT group were performed in a "functional position" rather than lying down; and (4) intensive cardiovascular exercises were recommended in the EAT group but not in the control group.

Significance was tested by a Student t test with Bonferroni correction factor for parametric values and [[Theta].sup.2] and Fisher's exact test for nonparametric values. The 8 participants who withdrew were not included in the analysis.

Six weeks after surgery, more subjects in the EAT group than in the control group were pain-free. At other follow-up times, no significant differences existed between the groups. In patients with residual leg pain, pain intensity was significantly less in the EAT group at 6 and 12 weeks after surgery than in the control group. Twelve weeks after surgery, the range of motion of the trunk improved significantly in the EAT group compared with the control group. At the 1-year follow-up, extension of the trunk increased significantly in the EAT group, and flexion of the trunk increased significantly in the control group. Hamstring length increased significantly in the EAT group 12 weeks after surgery. At the 1-year follow-up, however, there was no significant difference. Twelve weeks after surgery, 15 subjects (58%) in the EAT group and 10 subjects (38%) in the control group returned to work. Two years after surgery, 96% of the subjects completed a questionnaire. Twenty-two subjects (88%) in the EAT group and 16 subjects (67%) in the control group were satisfied with the results of the treatment program.

The authors concluded that, overall, the EAT program provided better results than the less-active training program. Both home training programs were designed to be inexpensive and require less time for the physical therapist compared with supervised training in the clinic.

William J Barnes, PT
Lincoln Physical Therapy Associates and
  Work Adjustment Center
Lincoln, Neb