ID Design 2012/DOOEL Skopje, Republic of Macedonia

Open Access Macedonian Journal of Medical Sciences. 2016 Dec 15; 4(4):661-664.
https://doi.org/10.3889/oamjms.2016.121
eISSN: 1857-9655
Clinical Science

Influence of Early Intensive Rehabilitation on Functional Mobility

after Low Back Surgery

1 1 2 1 1
Tsvetelina Bizheva , Daniela Lubenova , Ivan Maznev , Kristin Grigorova-Petrova , Antoaneta Dimitrova , Danche
3* 1
Vasileva , Milena Nikolova

1 2
Department of Kinesitherapy and Rehabilitation, National Sports Academy “V. Levski”, Sofia, Bulgaria; Department of
3
Sports Medicine, National Sports Academy “V. Levski”, Sofia, Bulgaria; Faculty of Medical Sciences, Goce Delchev
University, Shtip, Republic of Macedonia

Abstract
Citation: Bizheva Ts, Lubenova D, Maznev I, Grigorova- AIM: The research aims to determine the influence of early goal-oriented physical therapy program
Petrova K, Dimitrova A, Vasileva D, Nikolova M. Influence
of Early Intensive Rehabilitation on Functional Mobility in combination with educational booklet and standard physical therapy without written instructions
after Low Back Surgery. Open Access Maced J Med Sci. on functional mobility outcomes in patients after low back surgery.
2016 Dec 15; 4(4):661-664.
https://doi.org/10.3889/oamjms.2016.121
Keywords: Rehabilitation; Functional Mobility; Surgery;
MATERIAL AND METHODS: Thirty patients with similar functional impairments were randomly
Postoperative period; Educational booklet; Physical divided into two groups, a control group (СG n = 10) and an experimental group (EG n = 20). The
therapy.
outcome measures include time to move from lying to sitting position, the TUG test and the 6-meter
*Correspondence: Assoc. Prof. Danche Vasileva, PhD.
Goce Delchev University, Faculty of Medical Sciences, walk test. Rehabilitation program includes daily physical therapy with mild to moderate intensity,
2000 Shtip, Republic of Macedonia. E-mail: achieving sitting position and education sessions how to perform activities of daily living (ADL) from
[email protected]
Received: 18-Nov-2016; Revised: 30-Nov-2016;
the first day after surgery.
Accepted: 01-Dec-2016; Online first: 03-Dec-2016
Copyright: © 2016 Tsvetelina Bizheva, Daniela RESULTS: There was a significant improvement from baseline in two groups for all performed tests
Lubenova, Ivan Maznev, Kristin Grigorova-Petrova, (p < 0.001). Statistical significant differences between two groups for transfers in bed on discharge
Antoaneta Dimitrova, Danche Vasileva, Milena Nikolova.
This is an open-access article distributed under the terms (p < 0.05), in one month (p < 0.01) and for TUG in one month (p < 0.05) were found.
of the Creative Commons Attribution-NonCommercial 4.0
International License (CC BY-NC 4.0).
CONCLUSION: The study revealed that early rehabilitation program consists of therapeutic
Funding: This research did not receive any financial
support.
exercises and written educational booklet after low back surgery improves transfer abilities and
Competing Interests: The authors have declared that no basic activities in one month.
competing interests exist.

Introduction complications, pain or dissatisfaction.

The aim of the research is to compare the
influence of a physical therapy program that combines
Degenerative spinal diseases are common active exercises with written instructions (educational
disorders and they are a significant social problem. booklet) about activities of daily living (ADLs) based
Spine surgery due to degenerative diseases is on guideline recommendations, or oral information on
associated with prolonged hospital stay [1]. functional mobility in patients after low back surgery in
Low back pain is second to upper respiratory one month after an operation.
problems as a symptom- related reason for visits to a
physician. There are wide variations in care, a fact
that suggests there is professional uncertainty about
the optimal approach. Magnetic resonance imaging
Material and Methods
has come to be widely used, the roles of exercise and
bed rest have been clarified, and more information Thirty patients, voluntarily attended and were
has been gained from clinical trials [2]. The integrated treated in the Department of Neurosurgery at
program of early rehabilitation improved the outcome University Hospital Sofiamed - Sofia was randomly
and shortened the hospital stay without more divided into two groups, control group (СG n = 10) and
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Clinical Science
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experimental group (EG n = 20). All patients had The CG was on the standard physical therapy
similar impairments and functional limitations. The program and instructions on how to continue exercise
mean age of EG is 55.9 ± 13.8, of CG is 58.3 ± 9.5. at home and to resume daily activities gradually.
The mean length of stay for EG is 3.9 ± 0.9; for CG is
3.6 ± 0.7 days. There were no significant differences Table 3: Instructions to patients after discharge from hospital
in the age and length of hospital stay in both groups. N ADL Instructions
Put a pillow under knees when lying on the back, and between knees
1. Lying
when lying on one side.
Table 1: Overview of the physical program Getting up
2. Sit in and get up from bed by first turning to one side
from bed
Steps Goals Activities - lying on the back, bend both legs and place one heel on the other
Breathing exercises/ combined Putting on knee
3.
Increase respiratory capacity with movement of the upper shoes [6] - in standing - tread on the shoe rack, or tread with one knee on the
Preventing
-improvement of peripheral limbs, floor
complications
circulation diaphragmatic breathing During prolonged sitting before you stand up, perform several forward
Sitting in a
Abdominal drawing in manoeuvre 4. and backwards movements of the pelvis. Do not sit in one place for
chair
Transfers and bed mobility more than 20 minutes
Take a sitting Self-moving in bed
exercises for upper and lower When getting up from a chair body should bow forward, hands push
position Getting up
limbs in bed 5. from the hips. Hands can be used for support in sitting, too. Avoid low
from a chair
To increase the strength of and soft armchairs and sofas.
Strengthening the abdominal exercises, isometric
muscles forming lumbar muscle
spinal muscles exercises, PNF
corset. To get subject without reaching or bending, it has to be on the level
Training in walking Improve posture Exercises for posture Getting between hip and shoulder. When you need to take products from the
6.
Improve gait Training of gait subject [6] refrigerator or stove, while bending the shoulders, you must slightly
Home exercise program (HEP) outsource back leg back and up, so that the body is not excessive
Patient’s education in
Prevention and long-term self- Healthy posture bent.
ADL
care for the back Balanced position of the spine
and extremities 7. Lifting Lifting the weight from the floor is through the squat, keep the weight
close to the body
Getting the Getting the objects above the head should not be done with tightening
8. objects above the body, but standing on something that will bring the subject to the
Outcome measures include transfer from lying the head level of the head.
to sitting position, Timed Up and Go (TUG) test [3] 9.
Washing In activities when we lower the upper part of the body, we can carry
dishes [6] the pelvis slightly back, with a little step one foot back
and walking speed for a six-meter walk test [4].
Driving a car Avoid driving at least one week after surgery. While sitting in a car, do
Transfer time was assessed by instructions which 10
[6] the seat back angle greater than 90 degrees. Avoid bending,
were given to the patient to sit up with legs down. especially when you get out of the car.
Place a rubber mat on the floor to avoid sliding. If necessary, lay
Getting a
Time for independent sitting without touching the bed 11.
shower
handles a convenient location to help with getting up from the toilet
seat bath
with hands was measured. All the tests were 12. Ironing Ironing table should be at elbow level, you can use a chair to sit.
measured three times, on the first day after surgery, 13. Carrying
When carrying purchases, the weight is distributed evenly in both
hands
on the day of discharge and one month later.

Table 2: Exercises and Instructions Statistical analysis was performed using

SPSS 19.00 for Windows. Independent sample t-test
Exercises Instructions Time
Exercises in supine
Training transfers to bed (until the drain is removed),
5-6 and chi-square test were used to examine the
Neurodynamic glides min.
Pivot does not twist with
baseline characteristics of two groups for age and
neutral spine with all
The physical therapist helps patient to transfer from one gender. Independent and paired sample t-tests were
transfers and bed 2-3
mobility
position to the next, sit at the side of the bed without
rotation (using techniques for convenience).
times conducted to determine the effect of the intervention
Posture principles for
ADL
on and transfers in bed, TUG and six-meter walk
Stabilisation exercises in
The first verticalization is with or without a belt according 3-4 speed. Statistical significance was set at p < 0.05.
supine-sit -standing with
to the intervention. times
no weight
Strengthening the
5-10
muscles that support Without pain
times
the lower back
Patient’s education focuses on the acquisition of
Training in ADL
- lifting subjects,
information and technical skills and transition to self-
fulfilling action, which facilitates patients, helping them to
10 Results
footwear, clothing min.
make decisions and take appropriate action when
- Golfer’s lift and reacher
changes in their disease or condition [6].

Walking to a place in No significant differences in the groups'

countries of the right and
left,
Reinforcement techniques transfers, sit and walking,
training in walking, climbing down and upstairs and pick
baseline characteristics were found. There was a
10-15
Walking back, up the object from the floor [6].
min.
significant improvement (Table 4) from baseline in two
Skip the subject, The therapist helps with gait, balance and strengthening
Climbing down and up of lower and/or upper extremities. groups for all tests (p < 0.001). Statistical analysis
stairs found no significant differences between the two
groups, except for transfers in bed on discharge t (28)
= 2.64, p < 0.05, in one month t (28) = 3.44, p < 0.01
All patients performed daily physical therapy and for TUG in one month t (28) = 2.74, p < 0.05.
for 30 minutes with mild to moderate intensity
achieving sitting position from the first day after The walking speed for six meters during
surgery. Proprioceptive neuromuscular facilitation for hospitalisation improves with 0.2 m/s for EG and CG.
transfer positions, gait training (Table 1, 2) and an The time for transfers starts from 9.1 sec. for both
educational booklet with instructions (based on groups and improves to 6.1 sec. for EG and 7.7 sec.
guidelines recommendations) on how to perform for CG. The significant improvement in transfers and
exercises and ADLs at home for one month after TUG in one month was 4.8 sec. and 11.3 sec. for EG.
surgery (Table 3) were given to the patients of EG.
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 Bizheva et al. Early Intensive Rehabilitation and Functional Mobility after Low Back Surgery
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Table 4: Outcomes for both groups a significant difference between the two groups only in
Tests Group
1st assessment 2nd assessment 3rd assessment transfers in bed was achieved, probably due to the
Mean ± SD Mean ± SD Mean ± SD
short time of hospitalisation. Our research shows that
EG 9.1 ± 2.7 6.1 ± 1.7 4.3 ± 0.7 for a better recovery of functional mobility after spinal
Transfer (sec)
СG 9.1 ± 1.6 7.7 ± 1.7 5.5 ± 1.2
surgery, patients need at least one month.
EG 20.1 ± 6.5 14.9 ± 5.3 8.8 ± 2.5
TUG (sec)
СG 19.8 ± 6.3 16.5 ± 6.2 11.8 ± 3.5
The importance of written patient education
EG 0.4 ± 0.1 0.6 ± 0.3 1.0 ± 0.3
6 meters walk (m/s)
СG 0.4 ± 0.2 0.6 ± 0.2 0.8 ± 0.3
as an integral component of postoperative
rehabilitation is increasing [10]. This indicates the
SD- standard deviation; EG – experimental group; СG – control group.
need for developing a program for home practice and
self-performing exercises. Our opinion is that a written
educational booklet contributed in the restoration of
physical activity. The same opinion is shared by other
researchers [8, 10-12].
Discussion There are many pieces of evidence for the
effectiveness of outpatient physiotherapy post first
lumbar discectomy [11]. No particular methodology for
The research aims to determine the influence rehabilitation has proven to be the best yet. Engers A.
of early goal-oriented physical therapy programs in et al., (2008) compared different types of individual
combination with educational booklets compared to education and did not find significant differences [13].
standard physical therapy without written instructions There is a wide variation in physical therapy practice
on functional mobility outcomes in patients after low with respect to proper post-operative management. A
back surgery. There are different views of surgeons in home exercise program “HEP” was given by Michael
terms of the initial period of rehabilitation after surgery R, (2005) [7]. Leaflets with information about the
[5]. Seventy percent of surgeons prefer to mobilise behaviour after spinal surgery such as “Get Well
their patients out of bed on the very first day after Soon“ [14] and “Your Back Operation” [15] are
surgery, 20% on day 2 and 10% leave it until the available on the Internet. McGregor A. et al (2012),
patient feels able [6]. However, recent reviews on considers that the booklet was welcomed by patients
rehabilitation following lumbar disc surgery concluded and they valued the information [12]. In our
that there was insufficient evidence that rehabilitation, “Instructions To Patients After Discharge From
in general, could lead to a faster decrease in pain and Hospital”, we have also tried to give the most
disability. The physiotherapy interventions still remain important trends in the performance of ADLs in a way
unclear [7]. Despite the lack of evidence, we consider that is safe for the back and does not cause
that early physical therapy contributes to a better complications after surgery. Restrictions on lifting,
recovery of the patient and leads to a faster return to sitting and driving showed considerable
normal functional status. All our patients were inconsistencies within the recommendations given by
mobilised as early as possible, according to surgeons' surgeons [5].
instructions. They took a sitting position immediately
on the first day after intervention. Michael R, (2005) In his study, Danielsen J. et al. (2005) proved
describes that on the day after surgery, the patient that the postoperative disability is reduced at least in
demonstrated an expected amount of post-operative the first six months. He recommended intensive,
stiffness, range of motion (ROM) limitations and standardised exercise training that ignores the fear of
functional deficits [8]. Therefore, the first thing we provoking pain and begins four weeks after the
demonstrated and explained to the patient was: how surgery [16]. We started training in proper motion and
to perform movements in bed as in pivoting, not performance of ADLs immediately after surgery. Also,
twisting the spine in all transfers and bed mobility. we gave written explanations of the requirements of
Physical therapy is focused on functional mobility performance of ADLs, and added to the description,
(getting in and out of bed, transfers, and walking). We pictures for easy understanding. Thus, patients gained
consider that this contributes to a better recovery of confidence and self-esteem in their movements even
the patients and leads to a faster return to a normal before the discharge from the hospital. Care after
functional state. discharge shows greater variability. Proper
implementation of the ADLs and avoiding bending and
In the last few years, the mean hospital stay rotation, lead to faster recovery and increase the
has reduced from 6.6 days to 2.6 days (2011–2012), independence in daily living [5].
which means that the time for training the patients to
perform proper ADLs is limited [9]. Since The monitored basic activities (ТUG test)
hospitalisation is just a few days, the patients demonstrate that until the day of discharge from the
performed the rehabilitation program at home. In our hospital, patients still have limited abilities in functional
case, the mean hospital stay was 3.8 days. During mobility, which were normalised on the first month
this period, patients improved their transfer abilities after surgery. TUG was used in the study of Michael
and walking speed, but not sufficient to restore the R, (2005) and results showed significant
possibility of normal functional mobility. At discharge, improvements. He discussed that TUG is appropriate
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for monitoring the recovery in patients after spinal Disord. 2006;7:47. https://doi.org/10.1186/1471-2474-7-47
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Further investigations should be made to http://www.flextherapistceus.com/material/TLIF%20-%20pdf.pdf
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