No differences in post-operative rehabilitation across municipalities in patients with lumbar disc herniation

Patients with lumbar disk herniation are a common and financially important group of patients. It is estimated that around 1-3% of all patients visiting general practitioners suffer from disc herniation [1] Many of these patients are 30-50 years old and are productive members of society. According to the national Danish surgical spine database, DaneSpine [2], a total of 6,450 patients with disc herniation were operated in Denmark in the 2009-2013 period. Patients with lumbar disc herniation improve significantly after surgery. The number of patients on full-time sick leave decreases from 52% to 14% one year after surgery and the self-reported leg-pain intensity is significantly reduced. The literature provides evidence for the acute efficiency of surgery on patients suffering from lumbar disk herniation and concomitant sciatica [3].

In this study, rehabilitation is defined as post-operative exercise. Rehabilitation of these patients is a controversial topic as conclusive evidence of treatment efficacy is lacking. A systematic Cochrane review from 2014 [4] suggested that rehabilitation exercises initiated 4-6 weeks after surgery seem to be effective for pain relief and for improving patients’ functional status. Furthermore, the study shows that there is no increased risk of re-herniation due to rehabilitation. However, a more recent randomised controlled trial (RCT) from 2014 [5] suggested that, in the long term, participating in a comprehensive physiotherapy programme following lumbar disc surgery may not be superior to sham therapy. The Cochrane review [4] was also unable to find any significant difference in performance between supervised exercise and home training after instruction. A previous RCT from 2011 [6] showed no significant difference between long-term outcome when patients given an information brochure were compared with patients receiving extensive rehabilitation.

Prior to 2007, hospitals in Denmark were assigned the task of rehabilitation after surgery. Following a local government reform in January 2007, the responsibility for post-operative rehabilitation was transferred to the municipalities. The Region of Southern Denmark decentralised rehabilitation after surgery to a total of 22 municipalities. This carried a risk for considerable variation in rehabilitation within the legal framework. Rehabilitation is now managed by municipal rehabilitation centres, primarily by physiotherapists instructing teams of patients. In an attempt to minimise information loss in the process of transferring patients from the hospital system to the local rehabilitation facilities, the municipal reform placed the hospitals under an obligation to create individual rehabilitation plans for their patients.

The aims of this study were

1: To determine if there are differences in the post-surgical rehabilitation programmes in the various municipalities for patients with lumbar disk herniation in the Region of Southern Denmark.

2: To determine if there are differences in effectiveness in patient-reported outcome measures among the municipalities one year after surgery.

3: To evaluate the cooperation between hospitals and rehabilitation units across the Region of Southern Denmark.

METHODS

This is an observational and cross-sectional study. Data were obtained using both a questionnaire and an analysis of the one-year follow-up results of 789 consecutive patients operated due to herniated lumbar disc between June 2010 and April 2013 at the Centre for Spine Surgery and Research, Middelfart Hospital. The study was conducted as a collaborative effort between the University of Southern Denmark and the research unit at Middelfart Hospital.

Survey of post-surgical rehabilitation programmes

The survey was developed as a cooperative effort counting the Centre for Spine Surgery and Research surgeons and physiotherapists. The survey contained items regarding visitation, methods of training and general rehabilitation programmes being offered (Table 1). Prior to sending the surveys out to all physiotherapists in the municipalities, a mini pilot project was performed. This involved a visit to Middelfart rehabilitation centre and observation of physiatrists and patient groups during their training. The questionnaire was then administered to an associated physiotherapist. Feedback from this session led to reformulation of questions for a better understanding.

The questionnaire and project information was sent by email to the responsible physiotherapists in the 22 municipalities. The respective physiotherapists were subsequently contacted by telephone to follow up on their completion of the questionnaire.

Analysis of DaneSpine Registry Data

To investigate possible differences in patient outcomes after rehabilitation across the 22 municipalities, we analysed data from the local branch of the national Danish surgical spine database, DaneSpine on patients operated for lumbar disc herniation. All patients completed the one-year follow-up questionnaire. The outcomes analysis include the Oswestry Disability index (ODI) [7], the EuroQol (EQ-5D) [8] and the duration of sick leave. Improvements in ODI and EQ-5D among the different municipalities were compared using one-way analysis of variance (ANOVA). The Mann-Whitney test was used to compare the length of sick leave among the municipalities as these data were collected as ordinal values. Due to small sample sizes in some municipalities, a subgroup analysis including only the five municipalities with the largest sample sizes was performed. All analyses were performed using PASW 17.0 (IBM, Somes, New York).
A conservative p value threshold of p < 0.01 was selected due to the multiple concurrent analyses.

Trial registration: not relevant.

RESULTS

Municipality programmes

All 22 municipalities were contacted and all responded to our questionnaire. The key results are summarised below. The visitation, programmes offered, training and follow-up were similar among the 22 municipalities.

Visitation

To ensure that patients were referred to the right rehabilitation pathway within the municipality, different visitation factors were used. The three most frequently used visitation factors were the rehabilitation plans made by the hospitals (77%), knowledge of patient disability (77%) and individual patient interviews prior to the initiation of the rehabilitation programme (86%).

Programmes offered

All municipalities offer both individual and group training. Most municipalities also offer home-training after instruction (86%). This is typically used in addition to group or individual training, but can also be a stand-alone measure if the patient is performing very well. Typically, 6-8 patients participate in group training sessions. Two municipalities reported use of co-training, in which patients exercise in teams, but with individual programmes.

Individual supervised training is typically offered to patients with special needs. In 21 of the 22 municipalities, rehabilitation is performed by the municipal sector, while a single municipality outsources the task to a private clinic. Six municipalities on occasion have patients on waiting lists, with a maximum two-week waiting period.

Training

Rehabilitation typically starts 2-6 weeks after surgery, depending on recommendations from the hospital, which vary among the referring hospitals. Typically, training is offered twice a week under the supervision of 1-2 physiotherapists. A typical rehabilitation programme lasts approximately 8-10 weeks. In all municipalities, the rehabilitation programmes are organised by physiotherapists, who mainly deal with back pain patients. Two municipalities use additional occupational therapists to supplement such training as necessary.

The practical exercise instructions given to the patients are both oral and in writing. Two municipalities also use virtual exercise instruction. The training includes both static and dynamic exercises, primarily employing the patient’s own body weight. The use of equipment such as fitness balls and rubber bands is common.

Several rehabilitation sites also train with free weights and machines. The exercises performed vary widely, ranging from cardio training to balance training. All municipalities use stability training of the spine as a key feature in their programmes.

Follow-up

Basically there is no follow-up on patients after rehabilitation. In some rehabilitation sites, follow-up is implemented if deemed appropriate. In such cases, the rehabilitation plan is revisited or follow-up calls/meetings are arranged. Follow-up to the municipality is often implemented by as a status report or dialogue meetings, if requested.

Patient-reported outcomes
from the DaneSpine registry

There was no statistically significant difference in improvements in ODI and EQ-5D among the 22 municipalities (Table 2). Even when only the five municipalities with the largest sample size were included, no statistically significant difference in improvements in ODI and EQ-5D was seen. In our analysis outcomes based on the length of sick leave, the data showed that patients on longer sick leave had inferior outcomes than patients with a shorter sick leave. This result was observed regardless of whether the analysis included all the 22
municipalities or only the five municipalities with the
largest sample sizes (Table 3).

DISCUSSION

Reviewing the replies from the rehabilitation units across the Region of Southern Denmark, it seems that all of the 22 municipalities have succeeded in creating a uniform post-surgical rehabilitation service for patients operated for lumbar disc herniation. This finding is consistent with the fact that we were unable to detect any significant difference in the patient-reported outcome measures from the 22 municipalities or even among the five municipalities with the largest sample sizes. A correlation was observed between patient sick leave and outcome, which indicates that a longer sick leave
results in worse outcomes. Patients with short sick leave (0-6 months) had greater improvements in ODI and EQ-5D than patients whose sick leave was longer (> 6 months).

Because the post-surgical rehabilitation programmes offered by the 22 municipalities were similar as were also the one-year patient-reported outcomes, we were unable to determine the optimal schedule for post-operative rehabilitation of patients with herniated lumbar disc. This will require a prospective clinical trial in which subjects are randomly assigned to different rehabilitation programmes.

In this study, a somewhat surprising finding was the large difference in satisfaction with the communication between the various spine units in the region and the rehabilitation units. Since the primary element in the communication between the secondary sector and municipalities is statutory rehabilitation plans, there must be considerable difference in the quality of these plans. Several municipalities proposed different solutions for these problems. The main issue was almost non-existent communication between the hospital and the treating physiotherapists.

Municipalities generally wanted a better direct contact between the surgeon and the treating physiotherapist as questions or difficulties with the patient’s rehabilitation do occur. Some physiotherapists requested fixed office hours and, if necessary, email correspondence with guaranteed response time. Other physiotherapists suggested an annual meeting where the respective surgeons and local physiotherapists could meet and discuss issues relating to their common patients. Such seminars could also provide a framework for distribution of new knowledge.

CONCLUSION

In this study, we found no substantial differences in the post-operative rehabilitation programmes for patients with lumbar disc herniation among the 22 municipalities in the Region of Southern Denmark. This is evidenced further by the lack of significant differences in patient-reported outcomes among the patients in the various municipalities. A longer sick leave is associated with inferior outcomes. Of note, our study showed a need for increased cooperation and coordination between the hospitals performing the surgery and rehabilitation planning on the one hand and the municipalities providing rehabilitation on the other.

Correspondence: Rune Tendal Paulsen, Kirurgisk Sektion, Rygcenter Syddanmark, Sygehus Lillebælt, Middelfart, Østre Hougvej 55, 5500 Middelfart, Denmark. E-mail: Paulsenrune@hotmail.com

Accepted: 30 April 2015

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk