Results Summary
What was the research about?
Back pain is a common problem that makes it hard for people to work, move around, or take care of themselves and their families. Surgery is one treatment. But even after back surgery, some people still have disability, pain, and poor health.
In this study, the research team compared two programs to improve patients’ health and movement after back surgery:
- Cognitive behavioral physical therapy, or CBPT. A physical therapist helped each patient make a list of activity, social, and emotional goals. Patients learned skills to help them meet their goals, such as replacing negative thoughts with positive thoughts.
- Education. A physical therapist taught patients about topics that are important after back surgery, such as appropriate exercise and movement.
The research team wanted to see how each program affected patients’ pain, health, and physical function. Physical function refers to how well patients can move and do things like walk or climb stairs. In both programs, physical therapists talked with patients on the phone.
What were the results?
After one year, patients in both programs had about the same amount of improvement in disability, pain, physical health, mental health, physical activity, and physical function.
Who was in the study?
The study included 248 people who had recent back surgery at one of two surgical centers. One center was in Nashville, the other was in Baltimore. Of these patients, 86 percent were white, 12 percent were black, 1 percent were Asian, and less than 1 percent were Native American. The average age was 62, and 51 percent were women.
What did the research team do?
The research team assigned patients by chance to one of the two programs. Six weeks after surgery, patients filled out surveys and wore a device for one week that recorded how much they moved. They also took tests for physical strength, mobility, and walking speed. About eight weeks after surgery, physical therapists called patients in both programs once a week for six weeks. Six months after surgery, patients filled out surveys and wore the device to record movement. Twelve months after surgery, patients filled out surveys, took physical function tests, and wore the device to record movement.
An advisory board helped the research team plan and carry out the study. This board included patients, doctors, physical therapists, and a psychologist.
What were the limits of the study?
Because the research team didn’t compare these programs with usual care after back surgery, the team doesn’t know if the changes were because of the programs or something else. The same two physical therapists called patients in both programs. It’s possible that the therapists used CBPT language by accident when talking with patients in the education program. Other studies found that CBPT was most helpful for patients who were nervous about starting to move again after surgery or felt unsure about meeting their goals. Results might have differed if this study had included more patients who felt that way.
Future studies could focus on patients who are scared to move or feel unsure about meeting their goals.
How can people use the results?
Doctors and patients can use these results when considering ways to improve how patients feel and how well they can move after back surgery.
Professional Abstract
Objective
To compare the effectiveness of two telephone-based postoperative interventions on decreasing disability and pain and improving general health in patients after spine surgery
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 248 adult patients with recent spine surgery |
| Interventions/ Comparators |
|
| Outcomes |
Primary: disability, pain, physical and mental health Secondary: physical activity and physical function |
| Timeframe | 1-year follow-up for primary outcomes |
This randomized controlled trial compared the effectiveness of cognitive behavioral physical therapy (CBPT) with an educational program on decreasing disability and pain and improving general health in patients who had recently undergone spine surgery for a degenerative lumbar condition.
Researchers randomized patients to one of two programs. Two trained physical therapists worked individually with patients in both programs by telephone over a six-week period.
- CBPT program: A physical therapist helped each patient develop an activity plan and goals. During each session, the therapist introduced cognitive behavioral strategies such as identifying distractions or replacing negative thoughts with positive thoughts to help patients reach their goals.
- Education program: A physical therapist shared information about postoperative recovery including the importance of physical therapy, proper biomechanics, and daily exercise.
The study included 248 patients who had a laminectomy with or without spinal fusion and received care at one of two surgical spine centers in Nashville and Baltimore. Of these patients, 86% were white, 12% were black, 1% were Asian, and less than 1% were Native American. The average age was 62, and 51% were female.
Patients started the program eight weeks after surgery. Patients first completed surveys and physical function tests and wore a monitor to measure physical activity for one week. Six months after surgery, patients completed surveys and wore the physical activity monitor. Twelve months after surgery, patients again completed surveys and physical function tests and wore the physical activity monitor. Researchers measured physical function with three performance-based tests for strength, mobility, and walking speed.
An advisory board of patients, spine surgeons, physical therapists, a psychologist, and a physiatrist were involved in trial planning and implementation.
Results
After 12 months, the study found no significant differences between the two programs. Patients in both programs reported similar improvements in disability, pain, physical health, mental health, physical activity, and physical function.
Limitations
Without a usual care comparison, this study cannot establish with certainty that the changes from before to after the interventions were a result of those interventions. Because the same physical therapists delivered both programs, they may have inadvertently used behavioral therapy techniques with participants in the education program. Other research suggests that patients with high levels of fear of movement and low levels of self-efficacy may benefit the most from CBPT. Patients in this trial had a range of scores on these measures, which may have contributed to the similar overall effects between the programs.
Conclusions and Relevance
Overall, the programs performed similarly. Both telephone-based CBPT and education delivered by physical therapists may help improve disability, pain, and general health in patients who have had spine surgery.
Future Research Needs
Future research could compare these interventions with patients who may benefit the most, such as those with high fear of movement or low self-efficacy.
Final Research Report
View this project's final research report.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers said the report needed a more consistent structure so that it was clear how the specific methods and results tied to each of the aims. The researchers revised the report to make sure that the descriptions in the methods and results clearly tied to the stated aims.
- Reviewers asked for more consistent structure in presenting study outcomes, so that readers would be able to discern which analyses demonstrated significant or nonsignificant results. Reviewers also asked that the discussion be revised to also clarify the results in a way that would not overinterpret the significant findings. The researchers revised the methods and results sections to provide more consistent descriptions of the outcome measures and study results. They also removed any language in the results and discussion that overstated the findings.