Contrary to previous reports and often physicians' advice, rehabilitation utilizing cognitive behavior principles is as beneficial and more cost-effective than primary fusion for chronic low back pain, according to two new studies.1,2
The new findings "should alter clinical practice to improve advice to patients to help them make a decision," says lead author Jeremy Fairbank, MD, consultant orthopaedic surgeon at Nuffield Orthopaedic Centre in Oxford, United Kingdom. "It should also encourage surgeons to refer patients to rehabilitation 'with enthusiasm,' rather than implying that they will see them back when they have finished the rehab," he tells CIAOMed.
In the randomized, controlled trial of 349 chronic back pain patients from 15 centers across the United Kingdom, 176 patients were assigned to spinal fusion surgery and 173 to an intensive program of rehabilitation.1 Overall, 284 (81%) provided follow-up data at 2 years, at which point 48 patients assigned to rehabilitation had received rehabilitation and surgery, whereas seven surgery patients opted instead for rehabilitation. "Although some patients and surgeons were clearly not satisfied with the results of rehabilitation, many more have benefited and avoided surgical intervention," the authors conclude
Both groups reported reductions in disability during the 2 years of follow-up. The mean Oswestry disability index score changed from 46.5 to 34.0 among patients who underwent fusion, and from 44.8 to 36.1 among low back pain patients who participated in the rehab program. Participants in both groups performed similarly in the shuttle walking test and the Short Form-36 (SF-36) general health questionnaire.
Rehab still cheaper in the long run?
In a cost analysis of the same cohort, the average total cost per patient was estimated to be £7830 ($14,287) in the surgery group and £4526 ($8258) in the rehabilitation group, a significant difference of £3304 ($6028).2
Overall, there appeared to be a slight efficacy advantage to surgical treatment, but the differences were minimal considering the potential risk and additional cost of surgery, the authors conclude. However, they point out that if the number of rehabilitation patients observed having surgery continues to increase beyond 2 years and the modest treatment benefit persists, this conclusion could be amended.
"Neither surgery nor rehab offers a 'cure' for their symptoms," Dr. Fairbank says. "Patients should know that rehabilitation can produce an equivalent effect to major surgery [and] should be the first thing offered to patients with enthusiasm from surgeons."
In the study, the rehabilitation program comprised education and exercise 5 days a week for 3 weeks. It was led by physiotherapists and included consultation with clinical psychologists. Stretching, spinal flexibility, and cardiovascular exercises were combined with cognitive behavior therapy to identify and overcome the fears and unhelpful beliefs that many pain patients develop.
References:
- Fairbank J, Frost H, Wilson-MacDonald J, et al. Randomised controlled trial to compare surgical stabilization of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilization trial. BMJ. May 23, 2005; [Epub ahead of print].
- Rivero-Arias O, Campbell H, Gray A, et al. Surgical stabilization of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomized controlled trial. BMJ. May 23, 2005; [Epub ahead of print].