Running Head: LUMBAR FUSION AND RA

Lumbar Fusion and Rheumatoid Arthritis: An Annotated Bibliography

Cheryl M. Hubert
Pima Medical Institute
December 13, 2015

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Abstract

Rehabilitation of patients with rheumatoid arthritis is often complicated by osteopenia

and immunosuppression from a long history of the disease progression and years of steroid use.
Joint pathology, such as spinal stenosis and compression fractures of the spine are not
uncommon. Care must be taken when creating a rehabilitation program to avoid further damage
to already fragile structures. This annotated bibliography includes sources that provide
background information, rehabilitation principles and protocols, and expected outcomes from
treatment.
Keywords: rheumatoid arthritis, lumbar fusion, physical therapy, spinal surgery

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Annotated Bibliography

Crawford,C., Carreon, L., Djurasovic, M., & Glassman, S. (2008). Lumbar fusion outcomes in
patients with rheumatoid arthritis. European Spine Journal, 17(6), 822-5.
doi:http://dx.doi.org/10.1007/s00586-008-0610-4
Rheumatoid arthritis patients often experience a higher rate of complications
after lumbar fusion surgery, secondary to osteopenia and immunosuppression that are
frequent comorbidities to RA, however treatment outcomes have not been compared
(Crawford, Carreon, Djurasovic & Glassman, 2008).
The authors describe a retrospective study comparing outcomes of lumbar fusion
surgery between patients with and without a diagnosis of rheumatoid arthritis(RA). RA
patients were matched for age, gender, smoking status, level of surgery, & date to nonRA patients who also received posterolateral lumbar fusion. All patients received
antibiotics pre-operative to 2 days post-operative and physical therapy with
mobilization on the first day after surgery. They reported that the treatment outcomes of
both groups were similar, with the RA group showing slightly better results; 74%
compared to 63% of non-RA patients received good to excellent results. In this study
there were no significant differences in complications or non-fusion rates between
groups.
Nielsen, P., Jorgensen, L., Dahl, B., Pedersen, T., & Tonnesen, H. (2010). Prehabilitation and
early rehabilitation after spinal surgery: Randomized clinical trial. Clinical
Rehabilitation, 24(2), 137-48. doi:http://dx.doi.org/10.1177/0269215509347432

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Nielsen, Jorgensen, Dahl, Pedersen & Tonnesen (2010) investigated whether

prehabilitation and early rehabilitation improved outcomes after spinal surgery. In this
study, patients scheduled for elective lumbar spinal surgery were allocated to two
groups; a control group which followed a standard program and an intervention group
which received a special protocol including pre-habilitation, nutritional support, and
increased physiotherapy after surgery.
The control group received mobilization on the surgical day and 30 mins daily
physiotherapy with discharge on the 8th day. The intervention group received a 6-8
week pre-operative 30-minute daily home exercise program, protein supplement drinks
the night before and 4 times per day for 5 days post-operative, and intensive
mobilization on the day of surgery with 30 minute twice daily physiotherapy with a
discharge on the 5th day. Outcomes were measured using the Brief Pain Inventory
Questionnaire, the Roland Morris Questionnaire (to assess pain-related disability), the
sit-to-stand test, Timed up-and-go test, and the 15D test for health-related quality of life.
It was concluded that the intervention group had significant improvements in pain relief
and rate of recovery, as well as satisfaction. The intervention group also required a
shorter hospital stay by a mean of 2 days, or 29%.
This study included middle-aged subjects with degenerative lumbar disease, and
comorbidities did not include rheumatoid arthritis. Also there were several variables
between the control and intervention groups, confounding the effect size of each
variable.

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Soegaard, R., Christensen, F., Lauersen, I., & Bnger, C. (2006). Lumbar spinal fusion patients'
demands to the primary health sector: Evaluation of three rehabilitation protocols. A
prospective randomized study. European Spine Journal, 15(5), 648-56.
doi:http://dx.doi.org/10.1007/s00586-005-0884-8
In a prospective, randomized study with a 2-year follow-up, Soegaard,
Christensen, Lauersen, & Bnger (2006) compared three rehabilitation protocols for the
post-surgical treatment of lumbar fusion patients. Ninety middle-aged patients were
randomly allocated to three treatment groups; a video group, a caf group, and a training
group. The video group was given one-time oral instructions by a physiotherapist and
given a home-exercise video. The caf group was given the same instructions and home
exercise; additionally, they attended three group support meetings with other spinal
fusion patients.
The training group received individualized training for one hour, twice per week
for 8 weeks, including: conditioning; dynamic endurance focusing on back, abdominals,
and legs; and stretching exercises. The researchers approached this study as a costanalysis from the healthcare sectors point of view, with patient demands for further
service being a key measure. The conclusion was that both the caf group and the
training group were more cost effective than the video group. The researchers
highlighted the effect of a limited behavioral intervention (caf group meetings) on cost
savings.
Although this study used younger subjects (median age of 47), it supports the use
of therapeutic exercise for lumbar fusion rehabilitation, both in efficacy and costeffectiveness.

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Tarnanen, S., Neva, M., Dekker, J., Hkkinen, K., Vihtonen, K., Pekkanen, L., & Hkkinen, A.
(2012). Randomized controlled trial of postoperative exercise rehabilitation program after
lumbar spine fusion: Study protocol. BMC Musculoskeletal Disorders, 13, 123.
doi:http://dx.doi.org/10.1186/1471-2474-13-123
Tarnanen et al (2012) propose a treatment regimen for rehabilitation after lumbar
spine fusion to be compared with a control group receiving the standard treatment. The
proposed program consists of specific back strengthening exercises, aerobic training,
and patient education on control to maintain a neutral lumbar spine position. Exercises
are progressed in 6 phases of rehabilitation, with body position and purpose of each
exercise noted.
The actual RCT study has not yet been published. This is just a protocol for an
intended study, however, this article gives a good summary of background information.