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Phone Counseling Improves Spine Surgery Outcomes

April 21, 2015
Incorporating pre- and post-op phone counseling improves patient adherence to rehabilitation and exercise programs after lumbar spinal surgery.

Following a lumbar spinal surgery, patients can benefit greatly from targeted exercises and diligent rehabilitation, but oftentimes the greatest challenge is getting patients to be more dedicated towards those positive health behaviors.

However, researchers now believe the key to improving patient activation could be as simple as talking, literally.

A recent study by Johns Hopkins researchers found that utilizing phone counseling sessions before and after surgical intervention greatly improved patients' propensity to stick to exercises and rehabilitation after surgery.1,2 Subsequently, those patients reported less pain and disability, as well.

Helping Patients Through Phone Counseling

The phone counseling sessions, or Health Behavior Change Counseling (HBCC), used many of the same techniques of Motivational Interviewing (MI), a patient-centered counseling style designed to get patients educated, invested, and involved in their own self-care.3,4

Of 122 patients (aged 46 to 72) who had attended Johns Hopkins Hospital between 2009 and 2012 to receive surgical care for spinal stenosis, 63 received multiple HBCC phone sessions, including one detailed session prior to surgery and then two more "booster" sessions 6 weeks and 3 months after the procedure.

The HBCC group showed more participation in their exercises and rehabilitation following the surgery, which translated to noticeable differences in functional outcomes after 6 months after the operation. Seventy-four percent of HBCC patients showed significant improvements in standard measures of physical functioning and self-reported measures of pain, compared to only 41% of the control group.

"What this research shows is that through HBCC, patients can be supported to engage more fully in their physical therapy and home exercise following surgery. These individuals, as we have shown, experience greater reduction in pain and improvement in physical function following surgery," said Richard Skolasky Jr., ScD, lead author of the study and an associate professor of orthopedic surgery at the Johns Hopkins University School of Medicine, in Baltimore.

While not a panacea, MI has shown success in improving outcomes of patients with chronic conditions, like multiple sclerosis,5,6 diabetes, cardiovascular disease, and HIV.7  According to Dr. Skolasky, taking advantage of HBCC could be a significant way to improve patient outcomes following a spinal surgical intervention, although certain challenges may still persist.

Barriers to Post-op Care

Skolasky and colleagues documented common barriers that made patients resistant to the rehab process, one of those barriers being a concern for proper pain management.

"In our conversations with participants in this study, there was a general lack of awareness of how pain management would be handled," Dr. Skolasky said.

Almost half (48%) of the entire patient group expressed concern over their pain, worrying about post-surgical pain, increased pain during rehabilitation, or being weaned off medication too early.

"It is our belief that better pre-operative education and support would ensure that patients have realistic expectations about all aspects of their care, including pain management," Dr. Skolasky said.

Building Trust

According to Steven H. Richeimer, MD, an associate professor of anesthesiology and psychiatry at the University of Southern California, utilizing HBCC is an important tool to building a relationship of trust with the patient, which can translate to better outcomes.

"Patients have to be convinced that their pain can be handled, and the physical therapist has to be trained to be sensitive to these issues and adjust the physical therapy in ways that keeps (the patient) progressing," said Dr. Richeimer, who is a member of the Practical Pain Management editorial board.

Maintaining a patient's confidence in their physical therapy is a significant issue. More than half of the patients in the study expressed fear of certain movements and exercises exacerbating their condition.

If a patient is concerned about encountering pain during their rehabilitation session, the doctor could advise them to take their analgesic medication prior to the session. Other methods can be used, as well, like warm-up exercises, ice-cooling jackets, and TENS units (Transcutaneous Electrical Nerve Stimulation), said Dr. Richeimer.

"There are all kinds of things that can be done to help patients to navigate this. Mainly they have to be convinced that people care, that they're paying attention," he said.

Self-Efficacy Also Concern

Sixty-two percent of patients also expressed concern over a lack of self-efficacy:

  • not performing the exercises correctly
  • getting transportation to physical therapy sessions
  • handling their own self-care properly.

"All the barriers that (Skolasky, et al.) identify are really important, and they point to the fact that the patient has to be given a certain amount of pre-surgery, pre-rehab education—that they know they can affect their healing process, their recovery process," Dr. Richeimer said.

For clinicians, the most significant hurdle may be finding a way to implement these measures into clinical practice.

The Functional Recovery in Lumbar Spine Surgery Health Behavior Change Counseling intervention trial was supported by a grant from the Agency for Healthcare Research and Quality. The study's authors reported no conflicts of interest.


Last updated on: April 21, 2015
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