Exercise Improves Outcomes in Artificial Disc Replacement

Exercise Program and Lumbar Disc Recovery

A new study from Australia provides preliminary evidence that intensive exercise and cognitive behavioral training can improve the outcomes of patients who undergo artificial disc replacement in the lumbar spine.

"The findings suggest a structured pre- and postoperative exercise program implemented with a cognitive behavioral approach could improve recovery from lumbar disc replacement surgery and augment an early return to work," said John Booth, MD. "Moreover, the cognitive changes evoked may play a more important role in recovery than the physiological adaptations."

Booth presented the results at the 20th annual meeting of the North American Spine Society in Philadelphia.

In October 2004, the U.S. Food and Drug Administration approved the first artificial disc for treatment of single-level disc disease in adults. The artificial disc was created to address limitations inherent in spinal fusions, which reduce motion in the spine and may accelerate spinal degeneration. Disc replacement is intended to preserve spinal motion and, in theory, prevent degeneration in adjacent anatomy.

In their study, Booth, Jerry Day, MD, and colleagues randomly assigned 10 patients to a regimen of intensive exercise and CBT for four to five weeks before surgery and 12 weeks after surgery. Another 10 patients received normal patient care, including inpatient physical therapy.

"The main goal was to augment or promote activation post-surgery by addressing the patients' beliefs and fears about activity, injury, and pain," said Booth, of RehWork-Rehabilitation and Consultancy in Wollongong, New South Wales, Australia. Patients learn "how fear of pain, physical activity, and injury fuel the pain and disability cycle," he explained.

The intensive preoperative rehabilitation program involved weekly, supervised sessions in a clinic in addition to exercise at home for 20 to 30 minutes per day, five days per week. Within six weeks after surgery patients worked out for a minimum of 50 to 60 minutes per day. The exercises are designed to improve whole body and deep trunk muscle endurance, spinal stability, trunk mobility, aerobic capacity, and movement and coordination.

In the cognitive-behavioral portion of the program, researchers taught patients about the importance of physical activity in recovery from spinal surgery and reassured them that it was safe to progressively increase their activity levels following surgery.

The researchers reported that 12 weeks after surgery patients in the intensive rehabilitation program had the same amount of pain as those who received standard care. However, those in the more-intensive program could walk significantly further than the others and were significantly less fearful of using their backs. Although they tended to have lower disability scores, the differences were not statistically significant.

Booth says the results are "suggestive." For more definitive results, he and his colleagues will need to look at more patients. "We believe that the findings justify a more comprehensive study," he said.

It remains to be seen whether an intensive preoperative regimen might provide patients with sufficient functional and psychological improvements to opt out of disc replacement surgery altogether. Booth said he had not yet analyzed all of the study data, but he estimated that of the patients referred to him for intensive rehabilitation before disc replacement surgery, there are "probably 20-30% ...