Early Self-Directed Home Exercise Program After Anterior Cervical Discectomy and Fusion

A Pilot Study

Rogelio A. Coronado, PT, PhD; Clinton J. Devin, MD; Jacquelyn S. Pennings, PhD; Susan W. Vanston, PT, MS; Dana E. Fenster, BS; Jeffrey M. Hills, MD; Oran S. Aaronson, MD; Jacob P. Schwarz, MD; Byron F. Stephens, MD; Kristin R. Archer, PhD, DPT

Disclosures

Spine. 2020;45(4):217-225. 

In This Article

Abstract and Introduction

Abstract

Study Design: Pilot randomized controlled trial.

Objective: To examine the acceptability and preliminary safety and outcome effects of an early self-directed home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data: Little is known regarding optimal postoperative management after ACDF.

Methods: Thirty patients (mean ± standard deviation, age = 50.6 ± 11.0 years, 16 women) undergoing ACDF were randomized to receive an early HEP (n = 15) or usual care (n = 15). The early HEP was a 6-week self-directed program with weekly supportive telephone calls to reduce pain and improve activity. Treatment acceptability was assessed after the intervention period (6 weeks after surgery). Safety (adverse events, radiographic fusion, revision surgery) was determined at routine postoperative visits. Disability (Neck Disability Index), pain intensity (Numeric Rating Scale for neck and arm pain), physical and mental health (SF-12), and opioid use were assessed preoperatively, and at 6 weeks and 6 and 12 months after surgery by an evaluator blinded to group assignment.

Results: Participants reported high levels of acceptability and no serious adverse events with the early HEP. No difference in fusion rate was observed between groups (P > 0.05) and no participants underwent revision surgery. The early self-directed HEP group reported lower 6-week neck pain than the usual care group (F = 3.3, P = 0.04, r 2 = 0.3, mean difference = −1.7 [−3.4; −0.05]) and lower proportion of individuals (13% vs. 47%) using opioids at 12 months (P = 0.05). No other between-group outcome differences were observed (P > 0.05).

Conclusion: An early self-directed HEP program was acceptable to patients and has the potential to be safely administered to patients immediately after ACDF. Benefits were noted for short-term neck pain and long-term opioid utilization. However, larger trials are needed to confirm safety with standardized and long-term radiograph assessment and treatment efficacy.

Level of Evidence: 2

Introduction

Anterior cervical discectomy and fusion (ACDF) is the most common cervical spine surgery.[1,2] The number of ACDF procedures has steadily increased over the last two decades,[1–4] with approximately 120,000 performed in the United States each year.[2,5] Average hospital charges for ACDF are estimated at more than $50,000 and rising,[5,6] resulting in more than $5 billion in total charges annually.[6] Despite the increased utilization, persistent neck and arm pain and disability are reported in up to 50% of patients.[7,8] Variability in the utilization of rehabilitation after ACDF may contribute to these poor outcomes.[9]

Rehabilitation is often initiated 4 to 6 weeks after surgery.[9] However, two systematic reviews highlight a lack of evidence for guiding postoperative rehabilitation.[10,11] One randomized trial has shown rigid collars improve function and pain after ACDF, but the quality of evidence was very low.[12] Wibault et al[13] randomized patients to structured rehabilitation or usual care at 6 weeks after ACDF and reported better 6-month outcomes following rehabilitation for expectation fulfillment and neck pain, but not in the primary outcome of disability. It is unknown if 4 to 6 weeks after surgery is the optimal time to initiate exercise. During the immediate postoperative period, there is reduced neck motion from fusion, pain, and postoperative restrictions (e.g., collar),[14–16] which affects neck muscle function and can lead to atrophy and deconditioning.[17] The loss of strength may not spontaneously recover and can persist several years after surgery.[18] Early initiation of exercise may counteract these deleterious effects.[19,20]

The purpose of this pilot study was to examine the acceptability and preliminary safety and outcome effects of an early self-directed home exercise program (HEP) performed during the first 6 weeks after ACDF. Our hypothesis was that the HEP would be acceptable to patients, show preliminary safety through no adverse events and revision surgery and comparable fusion rates, and demonstrate improvements in disability, pain, physical and mental health, and opioid utilization at 12 months after surgery compared to usual postoperative care. This study is informed by the lumbar spine surgery literature, which supports early postfusion rehabilitation that includes walking, education, neuromobilization, and core strengthening.[21,22] Results of this study will provide clinicians with a better understanding of early exercise benefits and inform future rehabilitation efforts.

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