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

Discussion

An early HEP was found to be acceptable, appeared safe, and offered an immediate benefit in neck pain. This pain modulating effect was not maintained at the 6- and 12-month follow-up timepoints. Early HEP participants were, however, less likely to be taking opioid medication at 12 months. Disability, arm pain, and physical and mental health were comparable between groups. These results appear to indicate that exercise during the immediate postoperative period is a potentially safe nonpharmacologic approach to postoperative pain management.

The early HEP was acceptable to study participants through high ratings on helpfulness and likelihood to recommend the program. None of the participants felt the efforts outweighed the benefits. Moreover, most (80%) participants in the current trial felt initiating exercise within 2 weeks after surgery was ideal. The dominant preference for early exercise initiation is a possible reason for 13 of the 15 participants adhering to the program. Patient preference is an important component of patient-centered medicine and shared decision making.[42] In nonoperative settings of patients with neck and back pain, preferences can shape expectations of benefit from exercise.[43,44] A greater understanding of preference and expectation for postoperative management is needed in patients undergoing ACDF.

The most common time to begin PT is 4 to 6 weeks after ACDF,[9] likely reflecting safety considerations. The current study, however, offers preliminary data on early exercise safety. In addition to the lack of group differences in fusion status, no participants required revision surgery for pseudarthrosis and there were no differences in neck pain that would suggest a higher rate of symptomatic pseudarthrosis in the early HEP group. Abbott et al[22] conducted a randomized trial of an early progressive psychomotor therapy program after lumbar fusion and found no increased risks in reoperation or pseudoarthrosis. In an observational cohort study, Machino et al[19] initiated early daily motion exercises immediately after cervical laminoplasty and found early mobilization may have contributed to preserved cervical alignment and motion. In other orthopedic populations, Villalta and Peiris[45] conducted a systematic review of early aquatic mobilization after shoulder, hip, and knee surgeries and found no increased risk and a potential benefit on physical functioning. Collectively, our pilot work and these previous studies show early rehabilitation strategies may be appropriate immediately after surgery. Further work is needed to confirm the safety of early post-ACDF exercise.

To date, one trial has examined the effect of postoperative exercise after ACDF. Wibault et al[13] compared a structured PT program that delivered neck-specific exercises and cognitive-behavioral strategies starting 6 weeks after surgery to usual care. Both the current pilot study and the trial by Wibault et al[13] showed no differences in primary outcomes at 6 months with intent-to-treat analyses. The current pilot study did report an immediate benefit in neck pain following the early HEP at 6 weeks. The immediate pain effect in the early HEP group compared to usual care was small and was not maintained at 12 months. Interestingly, secondary outcomes related to patient perceptions of the importance of changes after intervention were favorable in both studies. Wibault et al[13] suggest that these outcomes may capture domains not currently represented in the other measures.

Lower opioid utilization was found at 12 months for the early HEP compared to usual care. This finding may be due to the early introduction of pain management strategies, which may influence downstream medication use. In patients seeking nonoperative care for neck pain, Horn and Fritz[46] found early PT was associated with lower risk of receiving an opioid prescription at 1-year from the index visit compared to patients receiving late PT. Future research will need to definitively establish whether postoperative strategies can not only improve outcomes, but also suppress the overutilization of opioids.

The strengths of this study include the randomized trial design, novelty of examining an early HEP, and long-term patient-reported outcome assessment. There were notable limitations that need to be considered. First, the study was not a fully powered and definitive randomized trial. The intent of the study was to describe patient acceptability and preliminary safety and outcome effects. It is possible the lack of differences in outcome measures between the early HEP and usual care groups was due to the small sample size. In addition, treatment differences in neck pain and opioid utilization may be due to multiple outcome comparisons. This pilot project provides necessary preliminary data for larger multicenter trials to establish the safety and efficacy of early exercise for ACDF. Second, the evaluation of fusion status was determined at variable time points after surgery and at the direction of the evaluating surgeon. Only 17 patients received imaging appropriate for fusion determination. Although this evaluation likely reflects current surgeon practice, a standardized approach for determining fusion will be needed to properly evaluate safety. The safety findings of the current pilot study should be interpreted with caution. Third, adherence was determined with a written exercise diary and weekly phone calls. Written diaries are a common adherence strategy, however, may not be as accurate compared to other methods.[47]

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