008 Layout SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 3 INTRODUCTION Low back pain (LBP) is considered the most prevalent musculoskeletal disorder in Western civilization (Deyo et al 2002). Although most studies have been con- ducted in developed countries, a recent systematic review showed that LBP is quite common in Africa and a source of constant disability (Louw et al 2007). Spinal surgery is extremely prevalent and “ever increasing” in developed countries such as the United States (US), England, Australia and Scandinavian countries, with the likelihood of having back surgery at least 40% higher in the US than in any other country (Deyo and Mirza 2006; Lurie et al 2003). No studies are available on the rates of spinal surgery in Africa. Emerging data, however, indicates the potential for increased rates of spinal surgery in South Africa. Discovery, the largest medical aid fund in South Africa, has had a 112% increase in hospital admis- sions and use of magnetic resonance imaging for LBP in 2005 (Discovery Statistics 2005). This concurs with studies showing a direct correlation between increased use of high-tech imaging studies and increased preva- lence of spinal surgery in those geogra - phical areas (Lurie et al 2003). The success rate of spinal surgery for LBP is controversial with up to 40% of patients still experiencing pain and disability following spinal surgery (Deyo and Mirza et al 2006; Lurie et al 2003; Ostelo et al 2003). If persistent symptoms are present following surgery, post-surgical rehabilitation, consisting mainly of exercise in varying formats, is often prescribed to decrease pain and disability (Ostelo et al 2003). A recent Cochrane review, however, indicated that there is inconclusive evidence for the effective- ness of postsurgical rehabilitation pro- grams (Ostelo et al 2003). In the orthopedic domain, there are a number of studies into the effect of education on pain and disability, with outcomes ranging from “excellent” (Udermann et al 2004) to “poor” (Gross et al 2000). A recent systematic review of all preoperative education programs in the orthopedic domain found only studies relating to total knee and total hip replacements and no studies on spinal surgery populations (Johansson et al 2005). Thus, there is a lack of infor - mation on preoperative educational approaches for lumbar surgery for radicu - lopathy (LSR), including content, pre- ferred delivery method and need for such programs. The objective of this study was to determine whether there is a demand for preoperative education for LSR. MATERIALS AND METHODS This study consisted of 2 surveys. The first survey was conducted on patients in the postoperative period following LSR, while the second survey ques- tioned physiotherapists treating patients in the postoperative period after LSR. Ethical approval was obtained from the Committee for Human Research at the University of Stellenbosch where the study was registered. All subjects pro- vided informed signed consent. Sampling and subject description A convenience sample of 47 males and females, aged between 20 and 65 years, who had undergone LSR, including Preoperative education for lumbar surgery for radiculopathy R e s e a r c h A r t i c l e A BST R A CT: To date no studies have been published on preoperative education for patients who had lumbar surgery. The aim of this study was to determine if there is a demand for preoperative education for patients who had lumbar surgery for radiculopathy. A convenience sample of 47 patients who had lumbar surgery and a random sample of 141 physiotherapists involved in treating patients who had lumbar surgery completed a newly developed spinal surgery questionnaire. The data were analyzed using descriptive and inferential statistical tests. Results showed that 100% of the patients and 99% of therapists view preoperative education to be an important component for lumbar surgery for radiculopathy. The most important factors identified for inclusion in preoperative educational programs were reason for surgery, risks associated with surgery, limitations following surgery and more education regarding pain. The preferred method of education delivery was verbal one- on-one education. This study demonstrates that there is a demand for preoperative education for patients who had lumbar surgery. KEY W ORDS: LUMBA R; SURGERY ; RA DICULOPATHY ; PREOPERATIV E; EDUCATION; PHY SIOTHERA PY. Louw A, PT, MSc Louw Q, PT, PhD Crous L, PT, MSc Correspondence to: Adriaan Louw International Spine and Pain Institute PO Box 1574 Raymore, MO 64083 USA Adriaan@ISPInstitute.com 4 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 laminotomy, laminectomy and/or dis- cectomy for lumbar radiculopathy, and attended their first outpatient post - operative consultation with the surgeon, were eligible to participate. Exclusions included not being proficient in the English language, previous spinal surgery, decompressive surgery for conditions other than lumbar radiculopathy and other surgical interventions. Patients were recruited from five spinal surgery groups in the Greater Kansas City met- ropolitan area between March 1, 2006 and September 15, 2006 to represent patients in the Greater Kansas City metropolitan area. The physiotherapists were eligible to participate if they were licensed in Kansas and Missouri and actively involved in treating patients having under gone LSR at the time of the study. Exclusions included not being proficient in the English language or having less than two years of clinical experience. One thousand physiotherapists licensed to practice in Kansas and Missouri were randomly selected by the statistician by means of a statistical program to participate in the study. Measurement Tool A new questionnaire was designed to serve as the measurement tool for both the patient and physiotherapist studies. A review of electronic databases was conducted to search for questionnaires on educational needs for patients. Three questionnaires were reviewed for content and format to assist in the design of the questionnaire for this study (Asilioglu and Celik 2004; Macario et al 2003). Additionally, interviews with two spine surgeons, three physiotherapists and two surgical technicians were con- ducted to help design the questionnaire. To establish face and content validity, the newly developed spine surgery ques- tionnaire was sent to a panel of 12 inter- national experts in the field of spinal surgery rehabilitation, patient education and questionnaire design, accompanied by checklists for comments. Following the recommendations of the expert panel review, changes were made to the newly developed spine surgery questionnaire, including a pain section and minor gram- matical corrections. The updated spine surgery questionnaires and checklists were then distributed to a convenience sample of five patients who had LSR in the past three weeks as well as a conve- nience sample of five physiotherapists actively involved with treating patients having undergone LSR. After the pilot studies no changes were required of the spine surgery questionnaire, thus deem- ing it ready for implementation for the main study. The final spine surgery questionnaires were organized into three sections: Section one - instructions on completing the questionnaire; Section two - demo- graphic information and Section three consisting of a series of 29 questions regarding educational needs, divided into five categories (Table 1). A 10cm linear scale was used to rate the impor- tance of a question being answered by the patient, ranging from “not important” to “very important.” At the end of each section questions were asked to ascer- tain the preferred profession to deliver information in regards to that particular section. The questionnaires used for the patient and physiotherapist studies consisted of the same content, except therapists were asked to rate the impor- tance of the questions being answered for their patients based on their experi- ence treating patients undergoing LSR. Data collection procedure Patients were required to attend a routine follow-up visit with the surgeon one month postoperatively. Sixty eligible patients were invited; consent was obtained and then completed the ques- tionnaire before consultation with the surgeon. Completion of the question- naire took approximately 10 minutes. The completed questionnaires were placed in self-sealed envelopes and handed to an independent administrative assistant. Data were collected between March 1, 2006 and September 15, 2006. Collected questionnaires were examined against inclusion/exclusion criteria, num- bered and catalogued accordingly, and recorded. To collect data from the physiothera- pists, a letter describing the research study, eligibility criteria and seeking permission to participate in the study was mailed to the 1000 randomly selected participants. All therapists were asked to return the survey within 60 days (Jette et al 2003). After 30 days, a Section Content 1: Surgical Procedure Anatomy, Pathology and Surgical Technique 2: Medical Care Blood transfusion, medication preoperatively, food and fluid intake preoperatively, anesthesia, medical clearance from their primary care physician, hospital stay, use of back brace postoperatively and consultation with the surgeon postoperatively 3: Prognosis Pain at the surgical site, pain “left over” after the surgery, “new” pains, overall prognosis and length of recovery. 4: Functional activities and restrictions Driving, lifting, bending, sitting, transfers in and out of bed, walking, needing physical therapy after surgery and content of postoperative physical therapy. 5: Education delivery One-on-one education, group education, methods videos, audiotapes and slides, color pamphlets, websites and who should deliver the preoperative education. Table 1: Surgery Questionnaire content. SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 5 Patient Study Physiotherapist Study Average age (in years) 46.13 (±10.92) Average age (in years) 41.65 (±10.56) Sex Highest attained degree - Male 21 (45%) - Masters degree 51% - Female 26 (55%) - Bachelor’s degree 43% Ethnicity - Doctorate degree 6% - Caucasian 85.11% Average years practicing - African American 6.37% as a physiotherapist 15.36 (±10.66) - Hispanic 4.26% Employment status - Asian 4.26% - Full-time 81% Type of surgery - Part-time 16% - Aware of the type of surgery 85.11% “- As needed” 3% - Laminectomy with discectomy 45% Practice setting - Laminectomy 25% - Private practice 46% - Microdiscectomy 20% - Hospital outpatient 26% - Discectomy 7.5% - Acute care 12% - Laminotomy 2.5% - Home health 6% Education - Other 10% - High school 53% Undergone spinal surgery 4 physio- - Graduate degree 32% themselves therapists - Postgraduate degree 17% (2.84%) Annual Income Formal Certification? - $10 - $50 000 53% - Yes 24% - $50 – 100 000 33% - No 76% - > $100 000 14% Table 2: Demographic data for the patient and physiotherapist study. postcard reminder was mailed to all participants thanking them for their participation and reminding them to return their questionnaires if they had not done so (Jette et al 2003). Returned completed questionnaires were tracked on the random sampling list. Data analysis The data was analyzed using descriptive and inferential statistical tests. RESULTS Demographics Forty seven patients completed the questionnaire. The typical patient under- going lumbar surgery for radiculopathy was a middle aged Caucasian male or female who was well-educated, aware of the surgery they underwent and on aver- age produced an annual income around $50 000 (US). One hundred and forty one physio- therapists completed and returned the questionnaires. Physiotherapists treating postoperative patients for LSR could best be described as middle aged physio- therapists with a Master’s degree, who have been in clinical practice for 15 years. These therapists were employed full-time in an outpatient orthopedic environment with no additional certi - fication. The demographic data for the patients and physiotherapists is presented in Table 2. Importance of preoperative education All patients (100%; n = 47) and 99% (n = 141) of physiotherapists surveyed perceived preoperative education to be important for patients undergoing LSR. On a scale of 0 (not important to know) to 100 (very important to know), patients averaged a score of 82.51, which indi- cates the significant importance of questions being answered to patients prior to LSR. Main themes extracted from the patient answers included: “better knowledge and understanding of the surgical procedure and be better prepared,” “need to know the risks asso- ciated with the surgery” and “decreased anxiety and fear.” Content of a preoperative education program The comparative ranking between the top 5 issues for patients and physiother- apists are shown in Table 3. • Surgical Procedure: Physiotherapists rated it significantly more important (p < 0.05) than patients to know about alternatives to the surgical procedure (p <0.01). Sub-group analysis indi- cated that outpatient physiotherapists were more inclined to rate alter - natives to surgery as important, com- pared to inpatient physiotherapists 6 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 treating the same postoperative patients (p = 0.03). • Activities, Mobility and Physio - therapy: Physiotherapists rated 4 out of the 5 questions as more important in being answered, compared to patients: return to work (p<0.01), starting driving (p<0.01), limitations with activities (p = 0.04) and the exact content of postoperative physio- therapy (p<0.01). • Pain and Physiotherapist expe - rience: In 3 of the 4 pain questions, less experienced physiotherapists rated it more important to educate patients regarding pain, compared to more experienced physiotherapists including issues regarding resolving the preoperative pain (p = 0.03), pain at the surgery site (p = 0.12) and “other” pain (p<0.01). Seventy three percent of therapists indicated that they did not receive any training in their undergraduate programs in regards to spinal surgery rehabilitation. • Pain, spinal surgery and pain science education: The majority of patients (74%) indicated pain as the main indication for undergoing LSR, followed by numbness and pain (23.91%). Forty-two percent of the patients indicated they were afraid the pain they were experiencing postoperatively would get worse. The majority of patients (85%) indi- cated that they expected to have pain following surgery, while only 53% of the therapists indicated that their patients expected to have pain fol- lowing LSR (Figure 1). Education delivery methods Verbal one-on-one education was the preferred means of delivering preopera- tive education for patients and physio- therapists in this study. In all categories, patients indicated surgeons as the pri - mary health care provider who should provide preoperative education. Ninety two percent of physiotherapists believed that preoperative education is more important than postoperative education with only 9% of physiotherapists pro- viding preoperative education in a struc- tured/formal program. DISCUSSION This is the first study to determine whether there is a demand for preopera- tive education for LSR. The importance of preoperative edu - cation Patients and physiotherapists regarded preoperative education for LSR as very important, concurring with studies in cardiology, general surgery and ortho - pedics (Asilioglu and Celik 2004; Lin and Wang 2005; McDonald et al 2004). Preoperative education in medicine is directed towards decreasing fear and anxiety associated with impending surgery (Asilioglu and Celik 2004; Lin and Wang 2005; McDonald et al 2004), which concurs with the results of this study. Decreased preoperative anxiety has been linked to a decrease in post - Patient Mean Question Patient Mean Question Rank Score Rank Score 1 94.04 How important is it for you 1 94.12 How important is it for your to know the exact reason patient to know about any for undergoing spinal limitations about activities surgery? such as bending, lifting, walking and sitting? 2 93.23 How important is it for you 2 93.74 How important is it for your to know the risks associated patient to know the risks with the surgery? associated with the surgery? 3 91.49 How important is it for you to 3 93.25 How important is it for know about any limitations your patient to know the about activities such as alter natives to the surgical bending, lifting, walking procedure? and sitting? 4 90.39 How important is it for you 4 92.00 How important is it for your to know how long it will take patient to know the reason to experience complete for surgery? loss of all pain? 5 89.91 How important is it for you 5 91.41 How important is it for to know how much pain your patient to know when before surgery will be gone they can return to work after surgery? after surgery? Table 3: Ranking by patients and physiotherapists of the 5 most important issues in regards to preoperative education for lumbar spine surgery. SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 7 operative pain, increase in return to work rates and improved functional activities (Lin and Wang 2005; McDonald et al 2004). Physiotherapist’s rating of preoperative education as more impor- tant than postoperative education may reflect that patients with persistent dis- ability and pain following LSR are more likely to be sent to physiotherapy for rehabilitation (Ostelo et al 2003), exposing physiotherapists to higher numbers of patients with persistent pain following LSR. Information required in preoperative programs for spinal surgery patients Three main topics were identified for inclusion in a preoperative education program for LSR patients: Reason for surgery, risk of the surgery and limita- tions following surgery. Reason for surgery was rated as most important because patients want to know how their disability will be addressed by surgery (Toyone et al 2005). More than 70% of the patients underwent surgery for pain, with or without neurological impair- ment. It can thus be argued that patients rated the reason for surgery important to understand how surgery will alleviate their pain (Toyone et al 2005). Risks factors (second highest rated) may sig - nify that an understanding of the risk of medical interventions, such as LSR, may be equally important than knowl- edge of the potential effectiveness of the proposed intervention (Murray and Lopez 1997). Pain and disability follow- ing LSR will not only impact on a patient’s physical well-being, but their work and social functioning which may lead to “disastrous emotional and finan- cial consequences to the patient (Onseti 2004).” Limitations following LSR (loss of range of motion, altered movement patterns and weakness (Onesti 2004; Ostelo et al 2003)) are also highly rated for pre-operative education for LSR, which concur with other orthopedic surgery studies (Hoerman et al 2001; Macario et al 2003). Addressing limi - tations is a very important part of a patient’s decision-making process regard- ing surgery (Toyone et al 2005) and apply not only to work-related activities but also to a person’s creative outlets, including sport, hobbies and recreation (Toyone et al 2005). By addressing limitations related to mobility as well as social impact, preoperative educational programs may help patients set realistic goals and expectations for recovery and return to function. Ninety-seven percent of the patients indicated that the preoperative education they received was beneficial, yet only 37% percent felt they received adequate information on pain. Patients are inter- ested in pain and should be educated more about pain (Moseley 2003). Pain science education for LBP has shown changes in pain beliefs and attitudes (Moseley et al 2004), improved cogni- tion and physical performance (Moseley 2005; Moseley et al 2004), increased pain thresholds and improved outcomes from therapeutic exercise (Moseley 2003; Moseley 2005; Moseley et al 2004). Pain science education may also decrease fear and anxiety associated with spinal surgery, potentially resulting in better outcomes following LSR (Moseley 2003). Fear of pain is a powerful contributor to chronic ongoing pain states (Waddell and Burton 2005) and 50% of patients expressed fear and anxiety about their persistent pain and were afraid that their postoperative pain would worsen. Physiotherapists’ interest in pain may be related to their own difficulty with treating pain, especially chronic pain (Latimer et al 2004; Moseley 2003). Seventy-three percent of therapists indicated that they did not receive any training in their undergra - duate programs on spinal surgery reha- bilitation, similar to studies highlighting the lack of pain science education in undergraduate training (Latimer et al 2004). Pain science education has been shown to ease student fears and increase knowledge in treating chronic pain (Latimer et al 2004) and physiotherapy programs should include pain science education as well as education on LSR. Educational delivery method Patients and physiotherapists preferred verbal one-on-one preoperative educa- tion, which concurs with other surgery studies (Hoermann et al 2001; Macario et al 2003) since it provides patients with a more interactive format and oppor - tunity for seeking answers to questions. This is in contrast to booklets and the internet which show modest results at best (Barrett et al 2002) and may be only a means of covering medico-legal aspects (Turner and Williams 2002). Only 4% of patients chose the internet/ websites for preoperative education, which strengthens the argument of one-on-one education. Expectations of pain postoperatively Yes No Yes and No P e rc e n ta g e 100 80 60 40 20 0 85 47 15 52 0 1 Patients Therapists Figure 1: Pain expectancies following spinal surgery. 8 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 Study limitations This study was limited by a small patient sample size which only included decom- pressive surgeries applicable to lumbar radiculopathy, and only patients between the ages of 20 and 65. Results may not be applicable to other spinal surgery populations, different etiologies and patients older than 65 or younger than 18, as these patients may have different educational needs. The questionnaire used in this study was not tested for reliability. CONCLUSION Patients and physiotherapists believe there is a demand for the development of preoperative educational programs for LSR. Preoperative educational programs should include education on reasons for surgery, risks associated with surgery, limitations following surgery as well as education regarding pain expectations. Verbal one-on-one education was the preferred method of delivery of pre - operative education for LSR. Future research should seek to determine if such preoperative programs produce superior outcomes. REFERENCES Asilioglu K, Celik SS 2004 The effect of preoperative education on anxiety of open cardiac surgery patients. Patient Education and Counseling 53:65-70. Barrett PH, Beck A, Schmid K, Fireman B, Brown JB 2002 Treatment decisions about lumbar herniated disk in a shared decision- making program. Joint Commission Journal of Quality Improvement 28:211-9. 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