Prehab for Lumbar Spinal Stenosis | Podcast Ep. 310

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week's episode, we're back with some research and this is all about Prehab for patients awaiting surgery for lumbar spinal stenosis. This is a brand new study and I cannot tell you the amount of times working in multidisciplinary groups that that the question of prehab came up. This study is a really, really great new look at the effectiveness of an exercise based prehab program for people waiting for lumbar spinal stenosis. We'll break down the results of this study, talk about why it matters, and also give you some clinical pearls to take with you for any of your patients that might have a surgery. Coming up on today's episode, we're talking about a prehab program for patients awaiting surgery, specifically surgery for lumbar spinal stenosis. And I said this at the top, but man working in multi, multiple, multi multidisciplinary groups. Throughout my career, the question of a prehab based program came up in so many different contexts so many times. Whether it was for potentially bundled payments, whether it was for improved outcomes on the surgery which enabled better negotiations with the payers, whether it was for patient satisfaction, whether it was for being able to get people ready for surgery who maybe were questionable candidates and really enable them to become good candidates for surgery through prehab as well. All of these things kind of came up time and time again. But the research out there today has been a little bit here and there. I don't think there's been really a great answer in terms of is prehab valuable? How does it really affect things long term? And I'm not sure that today's study really is the definitive study either. But it starts to get the conversation that direction, which I think is so important. Why is this so important? Well, it's important because lumbar stenosis is the most common reason for spine surgery in older adults. And that's a big deal. When we look at the numbers of surgical interventions taking place, specifically spine per year and it's well over a million and we see that the number one within that, the number one reason for spine surgery is lumbar spinal stenosis is a big deal. And we know lumbar spinal stenosis based upon neurogenic claudication, right? People telltale sign leaning over the shopping cart, somebody can go around the store forever. You take away the shopping cart and they're walking about 10 steps before they sit down to rest, to then do the same thing. All over again. So when you have that big pinch and compression on the spinal cord, it really has a negative effect on quality of life, you know, and that ultimately leads to increased mortality over time. So the ability to dynamically change, the ability to, number one, hopefully avoid surgery to begin with. But definitely for those individuals that are gonna go through surgical intervention, ensuring that they are as fit as possible going into that surgery, I think is a really, really good idea. Now we'll break down every aspects of the study, but basically what they found was significant but small improvements in favor of the experimental group at the post intervention assessment. And what were those benefits in? Benefits were in pain intensity, lumbar spinal stenosis related disability, lumbar strength inflection, low back extensor muscle endurance, total ambulation time and sit to stand performance. And a significant difference in the intervention group was found starting three months post operative for low back related disability. So all of those things, tell me, man, prehab is probably a good idea, uh, but let's dive into what some of this, some of what they found. So we know that the metabolic response that results from surgical procedures, it did a lot of changes that take place. There's changes in body composition, there's loss of muscle function and strength, there's decreased vasomotor control and sympathetic hyperactivity. All of these things. I don't care if your surgery is minimally invasive or whether it's a full on open surgery. Anytime you're cutting through the lamina, anytime that you're cutting through muscle, you're cutting through ligament, basically the body is going to take up that space. If you're removing tissue from the body, cutting through, retracting and removing tissue, there's only a couple things that can happen. One, the body's going to fill that space is what I'm getting at. And one of the ways the body will fill that space is through scar tissue. That's why there tends to be a lot of scar tissue. Number two, it could fill it with fluid collections. Why? Fluid collections are really, really common post surgically. Now most of the time they don't become seromas and become encapsulated, which is good. Which means that they dissipate throughout the following weeks after surgery. But an overwhelming majority of individuals who have spine surgery have a fluid collection post surgically, fluid gets in there to fill the space. The body does not like open spaces. But all of these things lead to challenges, right? You know, especially as we see people in the aged population. And lumbar spinal stenosis is the most Frequent degenerative condition in older age patients. And it's the, it's the primary reason for undergoing spine surgery in adults over age 65. So this is a big deal. Many of These individuals age 65 and above might not be in the best shape of their lives to begin with. Now you start to compound the negative effects, the challenges with surgical intervention and it's difficult to get up and moving again. And that's why, in my opinion, looking at prehabilitation, getting people as healthy as movement, as movement based health, you know, as moving as well as they can before they get into the or can be so critically important in their ability to get up and moving after the surgery itself. So important things to keep in mind. So in this study, participants in the exercise group, they were offered supervised exercise sessions three times per week for six weeks prior to their surgery. And a typical training session was five minutes of warmup. They might've done some cycling or walking on a treadmill, followed by 25 minutes of exercises with concentric and isometric phases. And this, the aim there was to improve muscle and structure involved in walking capability. So specifically focused on the ability to get up and ambulate. And they looked at over 64, about a hundred people, but there's some drop off. So about 64 participants underwent lumbar laminectomy or laminotomies over the course of the study. And none of them underwent a revision surgery within months to follow up. So that was also good. And we think about what's the difference between a laminectomy and a laminotomy? Pretty straight up. If you think about a laminectomy, that's the removal of the entire lamina. So it's taken the whole roof off. If you think about a laminotomy, it usually is leaving a superior arch of the lamina. So it's. While a laminectomy might be considered taking the whole roof off the joint, a laminotomy is creating a door or a window. So you retain some of the lamina in a laminotomy. You remove the entire lamina in a laminectomy. Now there's some. It's more art than science, so to speak, in terms of what qualifies as which. How it's billed and coded depends upon the surgeon a lot. And there's a lot of flexibility in terms of how exactly that could be defined. I've heard surgeons themselves sort of arguing over which one's which, but that's the general gist of it. So in this case the at the preoperative assessment, participants in the intervention group, so those who received exercise reported greater positive change in their global status compared to the control group. 69% reported their status had improved in the intervention group compared to only 11.5% in the control group. So that tells me that the ability to get up there, even for patients that were six weeks before having a surgical intervention for spinal stenosis, they found some significant improvement. Now, it might not have been enough to change their desire to have surgical intervention, but a lot had improved prior. And that's an important thing that tells me it was doing what we anticipated, which is help get people stronger before they have the setback of the surgical intervention. So in this study, the conclusion was the main objective of the present study was to evaluate the effectiveness of a six week preoperative exercise based program compared to usual care in patients awaiting elective surgery for lumbar spinal stenosis. Our findings suggest that while the intervention yielded improvements on clinical status and physical capabilities preoperatively, it was insufficient to foster a more rapid short term post operative recovery. So bottom line with this study is they said, well, the prehab was really good at helping get people stronger prior to that surgical intervention. However, they didn't see any big changes after the surgery in terms of their ability to quote, unquote, bounce back any quicker. So what do we take that as? I take it as getting people as strong as possible previous to any surgical intervention is a good idea no matter what, in my opinion. The second component of this that I think is important to take home is having people understand that when they have a surgery date on the books, and if it might be six weeks, eight weeks out, it doesn't mean it's time to just lay down and not do anything. And I know we've all had patients that that's been the case. Oh well, my surgery's coming up. That's gonna quote, unqu fix it. I don't need to do anything before then. I don't want to quote, I don't want to hurt myself. I'm going to have surgery anyway. And all of those are great conversation points for you to educate and really inform your patients and tell them, hey, you know, just because you're having surgery doesn't mean it's time to stop doing everything. What you should do is to stay as active as possible, everything you can do now until then, so that you go into that surgery as strong as possible. We know that surgery, you know there's going to be downtime. We know that there's going to be scar tissue. We know that there's going to be some post operative pain. And the best way is the best things you can do to mitigate that and minimize that is to go into that surgery as strong as possible. And some of the best things that you can do to go in as strong as possible is to stay as active as possible right up to that surgery. So I think this study is a really cool study. It's a good step in the right direction. I think what always waiting for really that prehab study that showcases such benefits after the surgical intervention. But the bottom line is this, is that us, if we're taking care of things pre and post surgery, we can't control what happens during the surgery itself. And surgery is traumatic under the best of circumstances. And the ability for somebody to bounce back after a surgical intervention in my opinion is going to be directly relative to their health status going into that surgery. So us as chiropractors I think have an important role in doing a couple things. Number one, interfacing and communicating with the surgeons in our area to letting them know, hey, we're a movement based health profession. And if you have patients going in that you think you'd like to have moving better, you'd like to really have better health status going in as far as their ability to ambulate, et cetera, then get them on over to our practice so that we can go through a prehab program. Maybe you could eventually even work with a surgeon on a prehab program. And that helps everybody, it helps fill your practice, it helps the patients clearly, and it also helps the surgeon get the best outcomes from their surgery. So if that's one direction you wanna go, I'd encourage you to start thinking about it. Look at studies like this, see what's out there. The other component of it is just being that beacon of light in your community. There's a lot of people out there going into surgery. Just as many that I said, maybe you wanna say I don't wanna do too much previous to the surgery. There's just as many people out there that are looking for things that they can do previous to a surgery to ensure that they have the best result. And if you're not out there telling that story, if you're not out there showcasing about it, how the heck are they going to know come in to see you? So using studies like this as fodder for your Facebook Live videos, for the conversations you're having with your patients, for posts that you're putting out there, maybe blog posts as well is a great idea to help plant the flag so people understand who you are and what you're about as a chiropractor. So hopefully this study was informative to you. I am still on the mend after a very very worst illness I've had in 20 plus years and I'm finally bouncing back but I am not back to where ideally like to be. Hopefully by next week I'll be back with full on energy. But I really appreciate you guys tuning in to the podcast. If you have not left us a rating or review I would love for you to do so. That helps more and more docs find out about what we do. And also before we wrap up I want to make sure that you check out Echiro EHR if you are into documentation and compliance. Every EHR sells features but few have Echiro's expertise. They can help you create a better lifestyle and improve your practice health. Echiroehr.com and finally, as we approach the holidays, Chiro Matchmakers we are like on fire right now. We have over 150 open jobs right now that are paying $85,000 or more. So if you are looking for your next career opportunity, head over to chiromatchmakers.com if you're looking to build and grow your team, we're happy to help you with that DC placement. Chiromatchmakers.com and finally our locum services are filling up for the holidays. So do not close your doors this holiday season and lose out on revenue and mess up your patient's care plans, et cetera. You don't need to do so. We have great locum doctors available throughout the United States. So if you're gonna be out of your practice, stay open, stay profitable. Visit chiromatchmakers.com have a fantastic week in practice. Have an awesome Thanksgiving if you're here stateside in the United States. I'll be back next week. Have an awesome week and I will talk to you soon.

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