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Accelerated
rehabilitation for
discectomy
patients Stephen Boyd – Physiotherapist
Nathan Wade – Exercise Physiologist
The reasoning
The reasoning
Case 1
• 32-year-old male
• employed as excavator operator
• 10 days unbearable sciatica
• unable to sleep
• large doses of analgesics
• disc herniation on MRI
• discectomy surgery
The reasoning
Case 1
Seen at 6 days post-op (Barricaid filming)
• minimal pain
• functioning equivalent to 3 week stage
• accelerated rehabilitation implemented
The reasoning
Case 1
2 weeks post-op
• minimal pain
• returned to full duties using excavator
• OTC medications
• returned to all normal activities
The reasoning
Pre-op 2 weeks post-op
The reasoning
Case 2
• 39-year-old male
• employed as a barge deckhand
• WorkCover claim
• 5 month history of sciatica
• failed to settle with injections
• large disc herniation on MRI
• discectomy surgery
The reasoning
Case 2
Seen at 10 days post-op
• early review as wanted to return to work
• minimal pain
• cleared for work
The reasoning
Pre-op 10 days post-op
The reasoning
Case 2
Seen at 6 weeks post-op
• reported that had worked 30 days straight
• performed full duties as a deckhand
• minimal pain
• OTC medications
The reasoning
Case 3
• 25-year-old stock filler
• Back and leg pain after lifting and twisting
• WorkCover patient
• Typical presentation and surgery
• Red flags
• Prolonged recovery
Not suitable for accelerated rehabilitation
The reasoning
Pre-op 3 months post-op
The evidence
The evidence
Caragee et al. (1996)
“lifting of post-operative activity
restrictions allowed shortened time
to return to work”
“average work loss was 1.2 weeks”
Kjellby-Wendt & Styf (1998)
“Patients rehabilitated
according to the early
active training program
(commenced 1 day post-
op) had a better short-term
outcome of objective
values”
McGregor, Burton, Sell (2007)
“early activation and return to
full activities as soon as possible
produces better relief of pain,
and return to work”
The evidence
Caragee et al. (1996)
“very early return to work did not
correlate with either recurrent
sciatica, reherniation or clinical
outcome”
McGregor, Burton, Sell (2007)
“early rehabilitation programmes
may improve function”
“early return to work is not
harmful, it can be helpful”
Newsome et al. (2009)
“Immediate commencement of exercise
following lumbar microdiscectomy enabled
patients to return to work sooner”
“no increase in the rate of revision surgery”
Our evidence
Out of the 257 discectomy surgeries
performed in 2012-2013 the revision rate at 12
months was 3%.
Only 3 recurrences (1%) occurred in the first 6
weeks.
• 1 occurred in hospital at 4 days post-op
• 1 occurred 5 days post-op
• 1 occurred 4 weeks ago
None were activity related
The process
The future
• Goal based vs time based
• Web based videos
http://www.spineplus.com.au/patient-
info/rehabilitation/spineplus-accelerated-
rehabilitation-program/discectomy-accelerated-
rehabilitation-videos/
• Regular communication (Skype)
The future
The future
Immediate (stage 1)
Progress to stage 2
The future
Stage 2
Progress to stage 3
The future
Post-operative
rehabilitation app