Ostelo R W, de Vet H C, Waddell G, Kerckhoffs M R, Leffers P, van Tulder M W
Department of Epidemiology, Maastricht University, Peter Debyeplein 1, PO Box 616, Maastricht, Netherlands.
Cochrane Database Syst Rev. 2002(2):CD003007. doi: 10.1002/14651858.CD003007.
Although several rehabilitation programs, physical fitness programs or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy and effectiveness of these treatments. There are still persistent fears of causing re-injury, re-herniation, or instability.
The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery.
We searched the MEDLINE, EMBASE and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, Issue 3.
Both randomized and non-randomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included.
Two independent reviewers performed the inclusion of studies and two other reviewers independently performed the methodological quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results.
Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately post-surgery, mainly because of lack of (good quality) studies. For treatments that start four to six weeks post-surgery there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs and there is strong evidence (level 1) that on long term follow up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There was also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months post-surgery are more effective in improving low back functional status as compared to physical agents, joint manipulations or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately post-surgery or later. None of the investigated treatments seem harmful with regard to re-herniation or re-operation.
REVIEWER'S CONCLUSIONS: There is no evidence that patients need to have their activities restricted after first time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks post-operative) on short term for functional status and faster return to work and there is no evidence they increase the re-operation rate. It is unclear what the exact content of post-surgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately post-surgery or possibly four to six weeks later.
尽管已经提出了几种关于腰椎间盘手术后患者恢复工作的康复计划、体能训练计划或指导方案，但对于这些治疗方法的疗效和效果知之甚少。人们仍然持续担心会导致再次受伤、再次突出或不稳定。
本系统评价的目的是评估首次腰椎间盘手术后用于康复的积极治疗方法的有效性。
我们检索了截至2000年4月的MEDLINE、EMBASE和Psyclit数据库以及2001年第3期的Cochrane对照试验注册库。
纳入首次椎间盘手术后任何类型积极康复计划的随机和非随机对照试验。
两名独立评审员进行研究纳入，另外两名评审员独立进行方法学质量评估。一个由四个科学证据水平组成的评分系统总结结果。
纳入了13项研究，其中6项质量较高。没有强有力的证据表明术后立即开始的任何治疗方法有效，主要是因为缺乏（高质量）研究。对于术后4至6周开始的治疗方法，有强有力的证据（1级）表明，与轻度运动计划相比，强化运动计划在功能状态和更快恢复工作方面（短期随访）更有效，并且有强有力的证据（1级）表明，在长期随访中，强化运动计划和轻度运动计划在总体改善方面没有差异。对于强化运动计划和轻度运动计划之间比较的所有其他主要结局指标，长期随访的证据相互矛盾（3级）。此外，与家庭锻炼相比，没有强有力的证据表明监督训练有效。与常规护理相比，多学科康复的有效性也没有强有力的证据。有有限的证据（3级）表明，旨在恢复工作的在职人群治疗方法在恢复工作方面比常规护理更有效。同样，有有限的证据（3级）表明，术后12个月以上开始的低技术和高技术锻炼与物理治疗、关节手法治疗或不治疗相比，在改善腰背部功能状态方面更有效。最后，无论运动计划是在术后立即开始还是稍后开始，没有强有力的证据表明任何特定干预措施添加到运动计划中有效。所研究的治疗方法似乎都不会对再次突出或再次手术造成危害。
没有证据表明首次腰椎间盘手术后患者需要限制活动。有强有力的证据表明强化运动计划（至少如果在术后约4 - 6周开始）在短期内对功能状态和更快恢复工作有效，并且没有证据表明它们会增加再次手术率。目前尚不清楚术后康复的确切内容应该是什么。此外，没有研究调查积极康复计划是应该在术后立即开始还是可能在4至6周后开始。
