Patient Activation Related to Adherence to Physical Therapy After Spine Surgery

Patients should participate in physical therapy after having spinal surgery on the lower back for degeneration injuries in order to help improve the success of the surgery, recommends the North American Spine Society. Because surgery can be done a considerable amount of time after the back pain has begun, by the time the patient has had surgery, there is a good chance that the muscles in the back have begun to weaken due to limited use. If you are feeling pain, you try to avoid making certain movements to aggravate the pain, for example. The limited movements mean the muscles aren't worked as often or as much as usual. Because of this, the muscles need to be retrained and the strength needs to be increased.

Despite the recommendations, some patients don't follow through with physical therapy after surgery and it could be better for surgeons if they could have a way of screening which patients would be more compliant than others in participating in post-surgery rehabilitation. It's known that patients with certain types of characteristics may be less likely to follow through with rehabilitation in general. This includes patients who are depressed, who have depressed attitudes, and who don't appear to have any motivation to work at recovery. It's also known that patients who see their physical therapy as an extension of their recovery management are more likely to participate actively.

Patient activation is a term that was coined to define how likely a patient may be to participate in actions and behaviors that will improve their chances of recovery. According to the authors of this article, "an active patient is one who is armed with the skills, knowledge, and motivation to be an effective member of the healthcare team." As patients are more apt to participate, their recovery rate usually rises, and this - in turn - can affect their psychological state. That being said, patient activation isn't something that has been tried with physiotherapy following surgery for lower back injuries.

The researchers in this study wanted to determine the association between patient activation and the success of physical therapy after lower back surgery for degenerative injuries. The researchers enrolled 65 patients who were a mean age of 58 years. There were slightly more females than men (58 percent were female) in the group. All patients had undergone spinal surgery for the first time. The patients participated in the six-week study by attending regularly scheduled physical therapy sessions. Three patients ended up not attending any sessions. It turned out that one wasn't able to pay for the sessions and the other two were not able to schedule convenient appointments.

The patient activation was measured using the Patient Activation Measure, a measure of 13 items. Each item is a statement, such as: When all is said and done, I am the person who is responsible for managing my health condition and I understand the nature and causes of my health conditions. For each statement, the patient is asked if they think the statement is true for them or not true for them.

Patients were also assessed using the Life Orientation Test, which measures optimism. For this test, the patient is told a positive statement and a negative statement, and are asked which is more true for them. Another measure was the Trait Hope Scale, which measured the patients' perceived ability to figure things out in order to reach their goal or goals. The researchers also had to measure the efficacy of the physical therapy and if the patients were showing any signs of depression. Finally, the patients were assessed during their final physical therapy session using the Hopkins Rehabilitation Engagement Rating Scale and they were asked to self-report how often they went to physical therapy.

In gathering the results, the researchers found that there were no differences in results between males and females, age, marital status, other illnesses, or education. However, they did find that nonwhite patients were more likely to score low marks on the Patient Activation Measure as were patients in the lower income scales. The income level was a major finding. In fact, nearly 75 percent of those who scored low on the measure had a yearly household income of less than 50,000 dollars, while 69 percent of the patients who scored highest were from households of more than 50,000 dollars per year. When looking at depression and patient activation, the researchers found that those who were more active, the less likely they were to be depressed or have symptoms of depression.

Whether a patient was active (showed up for and participated in physical therapy sessions) was clearly seen by the results that showed patients who did not actively participate also had lower confidence and hope for improvement. Patients who scored well in the Patient Activation Measurement, did well in physical therapy participation. The more self-assured and self-confident the patient, the better the attendance and participation rates.

The authors did point out that here were some limitations to their study. These include that there was no follow up with the patients to see how they did over the long term, the patients came from one particular medical group, and that the researchers relied on the patients reporting if they attended physiotherapy sessions or not. The authors also mentioned that the sample size was small, so making a general statement regarding patient attributes and physical outcome may not be that reliable. However, they pointed out that this study was a good start in showing that there is a relationship between how patients feel about themselves and how well they participate in rehabilitation following spinal surgery.

Richard L. Skolasky, ScD. et al. Patient Activation and Adherence to Physical Therapy in Persons Undergoing Spine Surgery. In Spine. October 2008. Vol. 33. No. 21. Pp. E784-E791.

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