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

Results

Participants

One hundred thirteen patients were assessed for eligibility (Figure 1). Of these, 35 participants (31%) were consented. Five participants were excluded after enrollment and before randomization for not completing the preoperative assessment (n = 3), cancelling surgery (n = 1), and having a documented history of drug abuse (n = 1). Thirty participants (mean ± standard deviation [SD]; age = 50.6 ± 11.0 years; 16 [53%] female; 25 [83%] White) were randomized to receive early HEP (n = 15) or usual care (n = 15) (Table 2). Twenty-eight (93%) participants completed all outcome assessments at 12 months. No group differences in baseline characteristics were observed, except early HEP participants had more comorbidities (mean ± SD = 4.3 ± 1.6) than usual care (mean ± SD = 2.7 ± 1.4) (P = 0.01).

Figure 1.

CONSORT flow diagram. HEP indicates home exercise program.

For discharge instructions, all participants were instructed not to lift more than 15 pounds or perform sudden or extreme neck movements. Driving restrictions varied from 2 to 6 weeks after surgery. Twenty (67%) participants were given a soft collar, with no difference between groups (early HEP = 9 (60%) vs. usual care = 11 (73%), P = 0.35). After 6 weeks, 13 (43%) participants, with 8 (53%) from the early HEP group and 5 (33%) from usual care, reported attending postoperative PT (P = 0.46).

Treatment Acceptability

The mean ± SD days with a valid report of adherence was 38.4 ± 4.4 and for performing exercise was 29.2 ± 11.9, corresponding to an adherence rate of 0.75 (95% CI: 0.60; 0.92). Participants reported high levels of helpfulness, likelihood to recommend program, and perceived benefits (Table 3). Other benefits included quicker recovery ("I recovered faster and felt better after my first week"), greater feasibility ("easier to do than going to PT" and "It's a good program. Especially since I used all my PT visits allowed prior to surgery"), and enhanced confidence for activity ("The program gave me the confidence to start exercising and not be afraid to move my head"). The ideal start time was reported as immediately after to within 2 weeks after surgery by 12 (80%) participants, whereas 2 (13%) participants stated before surgery.

Safety

No serious adverse events were reported. Two (13%) participants from the early HEP group reported minor neck pain or muscle soreness. Seventeen (57%) participants had adequate imaging to assess fusion status at follow-up and there was no statically significant difference between the two groups (P = 0.54) (Table 4). No participants underwent revision surgery based on self-report and a review of medical records.

Outcomes

Immediate improvements at 6 weeks were noted in the early HEP group for disability (mean change [95% CI] = −7.7 [−11.6; −3.7]), neck pain (mean change [95% CI] = −4.5 [−6.1; −3.0]), arm pain (mean change [95% CI] = −4.1 [−5.9; −2.2]), physical health (mean change [95% CI] = 4.9 [0.3; 9.6]), and mental health (mean change [95% CI] = 5.6 [0.7; 10.5]) (P < 0.05, Table 5). These changes exceeded MCID for disability, neck and arm pain, and mental health. Significant improvements were maintained for all outcomes at 12 months (P < 0.05), except for mental health. The usual care group demonstrated an immediate improvement in all outcomes (P < 0.05), except for physical health. The immediate change in neck pain (mean change [95% CI] = −2.7 [−3.4; −2.0]) and mental health (mean change [95% CI] = 8.1 [0.1; 16.2]) exceeded MCID. Significant improvements were noted in all outcomes at 12 months (P < 0.05). Multivariable regression analyses revealed a greater effect on 6-week neck pain in the early HEP group compared to usual care (F = 3.3, P < 0.05, r 2 = 0.3, Table 5). This corresponded to a −1.7 (95% CI = −3.4; −0.5) point difference on the NRS. No other between-group differences were noted (P > 0.05).

There were no group differences in the proportion of participants currently taking opioid medication at 6 weeks (early HEP = 3 [20%] vs. usual care = 8 [53%], P = 0.06) or 6 months (early HEP = 4 [27%] vs. usual care = 7 [47%], P = 0.23). At 12 months, there was a fewer proportion of participants in the early HEP group (13%) on opioid medication compared to usual care (47%, P = 0.05).

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