Abstract
Objective
Evaluating the efficacy of an intensive, dynamic and multidisciplinary spine-specific functional restoration program in patients with chronic low back pain with or without surgery.
Methods
One hundred and forty-four subjects with chronic low back pain included in the retrospective study and divided into two groups: patients who had spine surgery (GI, n = 81) and patients who did not have surgery (GC, n = 37). The two groups followed the same functional restoration program (175 hours). All the subjects were evaluated before (T0) and after (T5wks) rehabilitation care based on physical, functional, psychological and professional parameters.
Results
All outcome measures were significantly improved for all subjects at the end of the study, regardless of the group. Eighty-one percent of patients returned to work. The surgery group obtained better results at the end of the program for pain and back muscle isometric endurance measures.
Conclusions
The effects of the intensive program were validated; nevertheless, spine surgery seems to have a positive impact on some physical parameters of this spine-specific functional restoration program.
Résumé
Objectif
Évaluer l’efficacité d’un programme dynamique, intensif et multidisciplinaire de cinq semaines de restauration fonctionnelle du rachis chez des sujets lombalgiques chroniques opérés et non opérés.
Patients et méthode
Étude rétrospective portant sur 144 sujets lombalgiques chroniques inclus dans le programme et classés en deux groupes : avec chirurgie du rachis (GI, n = 81) et sans chirurgie (GC, n = 37). Les deux groupes ont suivi le même programme de restauration fonctionnelle du rachis (175 heures). L’ensemble des sujets a été évalué avant (T0) et après la prise en charge (T5sem) sur les paramètres physiques, fonctionnels, psychologiques et professionnels.
Résultats
Les valeurs mesurées étaient très significativement améliorées pour l’ensemble des sujets, quel que soit le groupe. Le taux de retour à l’emploi global représentait 81 %. Le groupe avec chirurgie du rachis obtient de meilleurs résultats à l’issue du programme pour les paramètres douleur et endurance musculaire isométrique des extenseurs du tronc.
Conclusions
Les effets du programme intensif sont confirmés, néanmoins, la chirurgie du rachis semblerait avoir un effet favorable sur certains paramètres physiques du programme de restauration fonctionnelle du rachis.
1
English version
1.1
Introduction
In several industrial countries, musculoskeletal disorders (MSDs) are becoming quite frequent, low-back pain is the most common, most debilitating and most expensive of all MSDs . Today, low-back pain remains a public health care issue. About 60 to 80% of the western population will have an episode of low back pain at some point in their life. Most patients with low back pain (90%) will get better in six weeks without any treatment, a minority of them will be in pain after three months (5 to 10%) progressing to chronic low back pain . It is well known that chronic low back pain is characterized by several factors: physical, functional, psychological and social ones . These past two decades, some specific programmes for chronic low back pain have been developed , based on Tom Mayer’s “deconditioning syndrome” concept . These programmes, with validated positive results , include multidisciplinary interventions and aim to get people back to work and resume their leisure activities. A spine-specific functional restoration program (FRP) was first introduced in France by the team of Vanvelcenaher at the end of the 20th century . Evaluating such programmes must be based on a cost-efficiency analysis and long-term patient follow-up. Thus, several cohorts of chronic low-back pain patients who benefited from a spine-specific FRP were monitored on the long-term. The treatment’s first target is physical deconditioning associated to changes in psychosocial factors in order to correct patients’ beliefs and behaviors.
The treatment prescribed must aim for pain relief, improving physical impairments, preventing recurrent episodes and informing the patients.
There are several articles in the literature reporting the efficacy of these types of intensive FRPs. However, to our knowledge, few studies concerned the specific effect of surgery in chronic low back pain patients. In this context, the aim of this study was to analyse the short-term efficacy of a spine-specific FRP and to compare, in our population of chronic low back pain patients, the answers to the FRP between the group of patients who had spine surgery and the group of patient who did not.
1.2
Patients and methods
1.2.1
Population
One hundred and forty-four chronic low back pain patients (73 men, 71 women) with a mean age of 41.5 ± 8.6 years were included in a spine-specific FRP after receiving a physical evaluation upon inclusion. All subjects were volunteers and referred by their primary physician. They were divided into two groups: one group of chronic low back pain patients who had spine surgery (GI, n = 37), one group of patients who did not have any surgery (GC, n = 81).
The inclusion criteria were: age between 18 and 65, chronic low back pain for more than three months, presence of a deconditioning syndrome and situation of therapeutic dead-end. The exclusion criteria were: psychological disorders, preexisting organic cause (acute or subacute degenerative disc disease, inflammatory or infectious pathology, tumor, neurological disorder, digestive disorders, cardiac pathology), additional benefits (financial), severe alcoholism or heavy smoking.
1.2.2
Intervention
The spine-specific FRP is based on a multidisciplinary pain management care, several professionals are involved: physicians, physiotherapists, occupational therapists, psychiatrists, physical education teachers and social workers. The main objective of this program was to restore movement and functional abilities of the patient rather than suppress pain. The patients were training seven hours a day, five days a week over a five-week period amounting to a total of 175 hours of training. The FRP included trunk and limb muscles reconditioning, cardiovascular exercises on a rowing machine, cycle ergometer for the upper and lower limbs, stretching movements and proprioception exercises.
The physician supervised the training sessions and adjusted the intensity of the exercises for each low back pain patient. During the first week, patients worked on flexibility and cardiorespiratory exercises. On the second week, they started strength training. On the third week, strength training was associated to endurance exercises. Patients performed weight-lifting, as well as coordination and proprioception exercises. During the fourth and fifth weeks, the intensity of strength training exercises increased progressively. Cardiovascular training (walking, running, cycling) was adapted to each patient and individualized. The program was completed by patient therapeutic education based on anatomical and physiological spine information, program’s principles and advice on healthy living before and after treatment.
This education was conducted with the full involvement of the medical staff and patient’s family. Stress, anxious-depressive factors and pain were managed through permanent visualization of the physical parameters’ results during tests and training sessions and with the help of relaxation and sophrology sessions. Once a week, patients with low back pain could have access to psychology counseling if they wanted. Appointments with the social worker were proposed each week to prepare the patients to get back to work and on which conditions.
A synthesis took place each week to monitor patient’s progresses.
1.2.3
Experimental protocol
Our study was retrospective, not randomized and conducted in a PM&R rehabilitation centre. In order to observe the adaptations and responses to the program, two evaluations were planned. The first one (T0) took place on the first day of admission before starting the reconditioning training program, the second (T5wks) happened at the end of the five-week FRP. To limit biological variations, tests were always conducted at the same hours and in similar settings. The initial evaluation was preceded by exercises to get familiar with the program so that postures could be done properly. Chronic low back pain patients from both groups were following, with no distinctions, the same spine-specific FRP.
1.2.4
Measured parameters
1.2.4.1
Demographics and clinical data
The physician from the PM&R centre collected patient’s data on age, weight, height, surgical history, duration of back pain, how long the patient has been out of work and smoking habits ( Table 1 ). The clinical interview also yielded information on the patient’s analgesics consumption and sports practice.
| Without surgery ( n = 81) | With surgery ( n = 37) | P | Mean ± SD | |
|---|---|---|---|---|
| Age (yrs) | 41.1 ± 9.4 | 42.2 ± 7.9 | ns | 41.5 ± 9.0 |
| Mass (kg) | 72.0 ± 15.4 | 71.0 ± 16.7 | ns | 71.8 ± 15.4 |
| Height (m) | 1.70 ± 9.1 | 1.71 ± 10.4 | ns | 1.71 ± 0.1 |
| BMI (kg/m 2 ) | 24.8 ± 4.1 | 24.0 ± 4.2 | ns | 24.6 ± 4.1 |
| Sick leave prior to inclusion (weeks) | 29.0 ± 38.5 | 43.8 ± 41.2 | ns | 34.0 ± 40.0 |
| Length of ongoing back pain (months) | 68.4 ± 64.8 | 86.4 ± 60.0 | P < 0.05 | 74.4 ± 63.6 |
| Smokers (%) | 33 | 37 | ns | 35 |
| Leisure time sport and physical activity: twice or more a week (%) | 21 | 19 | ns | 20 |
1.2.4.2
Quality of life
It was evaluated with the DALLAS self-questionnaire . This questionnaire is a specific scale, validated in French, assessing the impact of low-back pain in four areas: daily life activities, professional and leisure activities, anxiety–depression ratio and social life. The results are expressed in percentages going from 0 (no impact) to 100% (maximum impact).
Another questionnaire was handed out to patients to know more about their medication intake (analgesics, sleeping medicines) and the time devoted to a physical activity (DIY, walking, sports, professional and leisure activities).
1.2.4.3
Pain
Patients evaluated their pain using a visual analog scale (VAS) graded from 0 to 100 millimeters. In this tool, 0 corresponds to lack of pain and 100 to maximum pain .
1.2.4.4
Flexibility
The flexibility of the posterior plane was tested using the finger-to-floor distance (FFLD) and the finger-to-feet distance (FFD). FFLD measured, in a sagittal plane, the distance separating the extremity of the middle finger from the level where feet are flat on the floor. The subject was on a podium and after two warm-up sessions, performed a maximal flexion of the trunk without bending the knees. FFD was measured while sitting on the floor. This flexibility test eliminated the apprehension of trunk flexion by limiting the eccentric work of posterior muscles. Just like with the previous test, the subject, legs stretched, did a maximal flexion of the trunk. The result (in cm) indicated the distance between the extremity of the middle finger and the sole of the feet.
1.2.4.5
Muscular capacity
Muscle evaluation of trunk flexors and extensors was conducted on a regularly calibrated isokinetic apparatus (Cybex Norm). A ten-minute warm-up session on a rowing machine preceded the test. The subjects were standing up, lower limbs stabilized by counter-weights, knees at a 20° angle. The movement tested was flexion/extension around a horizontal axis going through the interline L5-S1. The movement amplitude was at 70°. The evaluation was done at three different speeds (30°/s, 90°/s, 120°/s), on a concentric mode, with respectively for each speed three, five and 20 repetitions and a two-minute rest between each series. The results were peak torque at 30°/s, strength at 90°/s and total work at 120°/s. For all these values, a calculation of the flexors on extensors ratio was computed (F/E).
Muscle endurance was assessed using the Sorensen’s test . The subject was placed prone with the legs fixed to the roman chair with a counter weight at Achilles’ tendons levels. After warming up, the test consisted in measuring how long the subject was able to keep the unsupported upper body horizontal, with arms folded across the chest. The test was stopped when the position could not be maintained any longer and/or when lumbar or pelvic pain set in. A chronometer was used to measure how many seconds the subject kept the position.
1.2.4.6
Load lifting
The load lifting test was adapted from the American progressive isoinertial lifting evaluation (PILE) . This dynamic test was used to assess effort endurance, physical ability and functional performance. The subject had to lift a box from the floor up to the 75 cm high table and put it back on the floor. The subject had to perform this box-lifting task four times (or eight movements) in 20 seconds. Testing was terminated when the subject could not lift the box four times within 20 s or when the subject decided to stop because of fatigue or pain. The starting weight (including weight of box) was 2.5 kg (5 lb) for women and 5 kg (10 lb) for men. After each completed lifting cycle, the weight was increased by 2.5 kg (5 lb) for women and by 5 kg (10 lb) for men.
1.2.5
Statistical analysis
The results were expressed as means and standard deviations. The statistical analysis was achieved with the Sigma STAT version 2.03 software. The results post-treatment (T5wks) were compared to the results pre-treatment (T0) for the 144 patients with chronic low back pain, using the Student t test for paired population data. A Student t test was also used to compare the data from both groups. To refine the interpretation of the studied parameters, the significance threshold was set at 5%.
1.3
Results
1.3.1
Population
One hundred and forty-four subjects were included in the FRP from January 2002 to December 2006. Out of the 144 subjects, 26 left the study because of incomplete evaluations. The comparison between the two groups, with and without surgery, was based on a total population of 118 subjects. The group without surgery had 81 subjects (GC) and the group with surgery had 31 subjects (GI). The total population ( Table 1 ) had a mean age of 41.5 ± 9.0 years. Mean BMI was 24.6 ± 4.1 g/m 2 . In this study, 46% of subjects with chronic low back pain were overweight (BMI > 25) with a higher proportion of men than women. Mean low back pain complaint was 74.4 ± 63.6 months. Two thirds of patients had to go on sick leave due to chronic low back pain, mean sick leave duration was 34 ± 40 weeks. A third of patients were smoking with a mean of 6 ± 11 cigarettes/day. Only one fifth of patients did regular exercise (two or more times a week). Using the French classification for socioprofessional categories (CSP), 38% of subjects were “employees” and 26% were “intermediate workers”. The subjects from GI had a longer pain complaint than subjects from GC ( P < 0.05): 68.4 ± 64.8 vs 86.4 ± 60, respectively. Besides the duration of low back pain, the population characteristics from both groups were identical.
1.3.2
Results at T0
The results at T0 for the entire population of patients with chronic low back pain reported moderate pain: 50 ± 22 mm, reduced functional load lifting capacities 25 ± 12% and decreased muscle endurance: 60 ± 45 s ( Table 2 ). The psychological impact of chronic low back pain on quality of life was significant for activities of daily life (ADL) at 75 ± 11%, work and leisure activities at 68 ± 16%, and anxiety and depression at 46 ± 20%.
| Short term effects of the FRP ( n = 144) | |||
|---|---|---|---|
| Variables | T0 | T5Wks | P Time effect |
| Pain (VAS, mm) | 50 ± 22 | 27 ± 21 | P < 0.001 |
| FTF distance (cm) | 13 ± 15 | −6 ± 8 | P < 0.001 |
| PILE (% mass) | 25 ± 12 | 44 ± 15 | P < 0.001 |
| Sorensen (s) | 60 ± 45 | 108 ± 47 | P < 0.005 |
| Ratio F/E 30° sec (PT, % of body weight) | 1.09 ± 0,28 | 0.86 ± 0.18 | P < 0.001 |
| Ratio F/E 120° sec (P, % of body weight) | 1.56 ± 1.19 | 1.07 ± 0.43 | P < 0.001 |
| Extensors trunk strength, maximal force 30°sec (peak torque, % of body weight) | 222 ± 81 | 307 ± 89 | P < 0.001 |
| Extensors trunk strength, endurance force 120°sec (total work, % of body weight) | 104 ± 63 | 211 ± 70 | P < 0.001 |
| Extensors trunk strength, speed force 90°sec (power, % of body weight) | 128 ± 69 | 236 ± 80 | P < 0.001 |
| DPQ daily activities (%) | 75 ± 11 | 47 ± 26 | P < 0.001 |
| DPQ work and leisure (%) | 68 ± 16 | 43 ± 27 | P < 0.001 |
| DPQ anxiety and depression (%) | 46 ± 20 | 29 ± 26 | P < 0.05 |
| DPQ sociability (%) | 27 ± 18 | 28 ± 24 | ns |
Before FRP, only lumbar-pelvic mobility was significantly better for the no surgery group (GC) than for the surgery group (GI): 93 ± 22 vs 83 ± 26 ( Table 3 ). Besides this difference in mobility, physical, functional and psychological parameters were identical.
| T0 | T5Wks | |||||
|---|---|---|---|---|---|---|
| Parameters | GI | GC | Mean ± SD | GI | GC | Significance |
| FTF (cm) | 15 ± 16 | 11 ± 13 | ns | −7 ± 10 | −6 ± 7 | ns |
| FTFe (cm) | 8 ± 13 | 5 ± 10 | ns | −8 ± 9 | −7 ± 7 | ns |
| Sagittal mobility (degrees) | 83 ± 26 | 93 ± 22* | * | 118 ± 17 | 118 ± 15 | ns |
| Pain, VAS (mm) | 46 ± 21 | 52 ± 22 | ns | 20 ± 20 | 31 ± 22* | * |
| PILE (% of mass) | 22 ± 11 | 25 ± 10 | ns | 42 ± 16 | 43 ± 14 | ns |
| Sorensen (sec) | 62 ± 56 | 53 ± 35 | ns | 129 ± 50 | 92 ± 38 | *** |
| Ratio F/E 30° sec (PT, % of body weight) | 1.13 ± 0.33 | 1.05 ± 0.24 | ns | 0.91 ± 0.20 | 0.85 ± 0.19 | ns |
| Ratio F/E 120° sec (P, % of body weight) | 1.39 ± 0.81 | 1.51 ± 0.70 | ns | 1.16 ± 0.48 | 1.02 ± 0.37 | * |
| Extensors trunk strength, maximal force 30°sec (peak torque, % of body weight) | 218 ± 93 | 221 ± 72 | ns | 299 ± 91 | 299 ± 86 | ns |
| Extensors trunk strength, endurance force 120°sec (total work, % of body weight) | 110 ± 65 | 101 ± 58 | ns | 202 ± 70 | 205 ± 64 | ns |
| Extensors trunk strength, speed force 90°sec (power, % of body weight) | 132 ± 70 | 121 ± 63 | ns | 220 ± 68 | 211 ± 64 | ns |
| DPQ daily activities (%) | 68 ± 17 | 68 ± 16 | ns | 39 ± 24 | 39 ± 24 | ns |
| DPQ work and leisure (%) | 65 ± 14 | 65 ± 19 | ns | 36 ± 18 | 36 ± 25 | ns |
| DPQ anxiety and depression (%) | 46 ± 26 | 51 ± 17 | ns | 27 ± 21 | 19 ± 21 | ns |
| DPQ sociability (%) | 36 ± 26 | 30 ± 19 | ns | 22 ± 18 | 20 ± 18 | ns |
1.3.3
Results at T5weeks
The short-term efficacy of the program ( Table 2 ), after five weeks of rehabilitation care was significant for the entire population, regardless of the parameters studied. Pain (VAS) decreased by 46% (50 vs 27 mm), flexibility, load lifting capacities and isokinetic performances of trunk extensors progressed, respectively, by 146, 76 and 57%. After the program, the inversion of the F/E ratio at slow and high speed validated greater muscle strength for trunk extensors. Isometric muscle endurance (Sorensen test) progressed significantly by 80%: the length of time the subject was able to hold the horizontal position went from 60 ± 45 to 108 ± 47 seconds (+80%). On a work level ( Table 4 ), 81% of subjects went back to work, 57% went back to their initial job and 24% went back to work with job adaptations. These adaptations mostly revolved around work time and nature of the job. The mean delay for going back to work was 30 ± 59 days for the entire population.
| Parameters | Percentage (%) | |
|---|---|---|
| Return to work | 81 | |
| With facilitations | 24 | |
| Without facilitation | 57 | |
| No return to work | 19 |
After the five-week training program, GI had significantly better results than GC for pain: 20 ± 20 vs 31 ± 22 mm; for isometric muscle endurance: 129 ± 50 vs 92 ± 38. Nevertheless, GC had a significantly better F/E ratio at 120°s than GI: 1.02 ± 0.3 vs 1.16 ± 0.48. Lumbar-pelvic mobility became similar in both group, furthermore, functional and psychological parameters were not affected by spine surgery, either before or after the training program.
1.4
Discussion
The main objective of this study was to compare the evolution between two groups of subjects with chronic low back pain, patients who had spine surgery and others who did not. The two groups were compared before and immediately after the spine-specific FRP. The efficacy of the program was validated by all the evaluated parameters and met the conclusions from the literature . This efficacy could be explained by daily isokinetic exercises, intensity and frequency of the training sessions (175 hours over a five-week period) and multidisciplinary rehabilitation care: physical, functional but also psychological and professional. The restoration of muscle strength in trunk extensors was based on an individualization of the program tailored to the physical and muscle capacities of each patient with low back pain. The efficacy of the retraining program was essentially centered on flexibility, strength and endurance . Even though this rehabilitation care was quite costly at 15 000 € , it was justified due to the therapeutic dead-end for all these patients and the mean duration of their chronic low back pain: 74.4 ± 63.6 months.
The subjects in GI had spine surgery mostly consecutive to a herniated disc (discectomy). For this same group, pain scores were significantly lower after treatment (T5weeks). These results validated the data from the literature on the positive effects of surgery on pain . Some authors reported a clear therapeutic impact of discectomy on radicular pain . The improved pain scores were significantly higher for patients with surgery (54%) compared to patients without (28%), these two groups reported mild pain at the end of rehabilitation care .
In this study, the comparison between both groups in terms of physical performances showed for GI at T5wks, significantly better results for isometric endurance strength: 129 ± 50 vs 92 ± 38 s for GC. The results from both groups on the Sorensen test at T5wks were in accordance with the normal values of a healthy population (133 s) for subjects who had surgery and in accordance with the normal values of a population with chronic low back pain (95 s) for subjects who did not have spine surgery . Dynamic and intensive spine-specific training would be efficient and well tolerated after surgery . Nevertheless, weaker results for GI at the end of the program (T5wks) for the ratios “flexors/extensors” at 120°s seemed to result from a non-optimal neuromuscular movement control and central inhibitions and might show the potential impact of surgery on spine velocity. Some studies did validate the decrease in trunk’s isokinetic strength after surgery . Muscle reinforcement exercises on an isokinetic apparatus played an essential role in FRP protocol. Several advantages could advocate their daily use . The isokinetic apparatus puts the subject in a safe position thanks to its joint amplitude control and the possibility to guide the movement. The contraction mode (eccentric or concentric) and exercise speed can make the workout sessions easier or harder. The results are in numbers and give precise information on the subject’s progresses (motivating impact). The isokinetic tool was used to evaluate, in a reproducible manner, trunk muscles performances and to assess muscular deficit of spine extensors.
Surgery did not have a positive impact before treatment for lumbar-pelvic mobility and the decrease of this mobility after surgery validated the data from the literature . Nevertheless, the differences between the two groups disappeared after treatment and showed a significantly better progression for the population who had surgery. After spine surgery, FRP allowed for proper recovery of the muscle-tendon complex properties at the sacrolumbar joint.
Besides these differences, most physical, functional and psychological parameters progressed positively and in a similar manner before and after treatment for both groups. The results seem to be similar even though the therapeutic endings are different . The European recommendations (COST B13) in terms of prevention and non-specific low back pain therapeutic care validate that invasive surgery is not more efficient than protecting treatments, such as FRP .
1.5
Conclusion
Subjects who had surgery had more muscle stiffness before the program than subjects who did not have surgery, yet they had greater improvement on pain and muscle endurance. Herniated disc surgery is not the solution for chronic low back pain but the major benefits of FRP in chronic patients even after disc surgery should be considered.
2
Version française
2.1
Introduction
Dans de nombreux pays, l’industrialisation a développé l’apparition de troubles musculosquelettiques, parmi lesquels la lombalgie est la plus fréquente, la plus invalidante et la plus coûteuse . Aussi, aujourd’hui, la lombalgie reste un problème de santé publique. Environ 60 à 80 % de la population du monde occidentale auront une lombalgie à un moment ou un autre de leur vie. La plupart des sujets lombalgiques (90 %) récupéreront en six semaines sans aucune intervention, alors qu’une minorité éprouvera encore des douleurs à trois mois (5 à 10 %), évoluant sur une lombalgie chronique . Le caractère multifactoriel de la lombalgie chronique : physique, fonctionnel, psychologique, professionnel et social, est aujourd’hui connu . Des programmes de prise en charge de la lombalgie chronique ont été développés durant les deux dernières décennies , basés sur le concept de Tom Mayer : le syndrome de déconditionnement . Ces programmes aux résultats probants , comprennent des interventions multidisciplinaires dont l’objectif principal est la reprise des AP et de loisirs. Un programme de restauration fonctionnelle du rachis (RFR) a tout d’abord été introduit en France par l’équipe Vanvelcenaher à la fin du xx e siècle . L’évaluation de tels programmes passe par l’analyse du rapport coût–efficacité et un suivi à long terme des sujets. Ainsi, plusieurs cohortes de patients lombalgiques chroniques ayant bénéficié d’un programme RFR ont été suivis.
Le déconditionnement physique est la cible première du traitement, associée à la modification des facteurs psychosociaux afin de corriger les croyances et le comportement du sujet. Le traitement prescrit doit viser l’antalgie, la récupération des déficiences physiques, la prévention des récidives et l’information du patient. La littérature concernant l’efficacité des programmes intensifs de type RFR est abondante. Cependant, à notre connaissance, peu d’étude se sont intéressées à l’effet particulier induit par la chirurgie chez les sujets lombalgiques chroniques. Dans ce contexte, l’objectif de notre travail était d’analyser l’efficacité à court terme d’un programme RFR et de comparer, dans notre population de sujets lombalgiques chroniques, les réponses au programme RFR des groupes avec et sans la chirurgie du rachis.
2.2
Patients et méthodes
2.2.1
Population
Cent quarante-quatre lombalgiques chroniques (73 hommes, 71 femmes) âgés en moyenne de 41,5 ± 8,6 ans ont été inclus dans un programme de RFR après une évaluation physique d’inclusion. Toutes les personnes étaient volontaires et adressées par leur médecin traitant. Les sujets ont été classés en deux groupes : un groupe de lombalgiques chroniques ayant subi une intervention chirurgicale du rachis (GI, n = 37), un groupe n’ayant subi aucune intervention chirurgicale (GC, n = 81).
Les critères d’inclusion étaient : âge entre 18 et 65 ans, présence d’une lombalgie chronique de plus de trois mois, présence d’un syndrome de déconditionnement et situation d’impasse thérapeutique.
Les critères d’exclusion étaient : troubles psychologiques, causes organiques habituellement reconnues (discopathie évolutive aiguë ou subaiguë, pathologie inflammatoire, tumorale ou infectieuse, atteinte neurologique, problème viscéral, pathologie cardiaque), bénéfices secondaires (financiers), dépendance sévère au tabac, à l’alcool.
2.2.2
Intervention
Le programme de restauration fonctionnel du rachis repose sur une prise en charge multidisciplinaire de la douleur, avec l’intervention de professionnels variés : médecins, ergothérapeutes, kinésithérapeutes, psychologues, psychiatres, professeur d’éducation physique, assistantes sociales. L’objectif principal du programme est de restaurer le mouvement et les possibilités fonctionnelles du sujet plutôt que de supprimer la douleur. Les patients s’entraînaient sept heures par jour, cinq jours par semaine, pendant cinq semaines, soit un total de 175 heures d’entraînement. Le programme comprenait un reconditionnement musculaire du tronc et des muscles des membres, des exercices cardiovasculaires sur rameurs, ergocycles à membres supérieurs et inférieurs, des étirements, de la proprioception. Le médecin supervisait les exercices effectués et ajustait l’intensité des exercices pour chaque patient lombalgique chronique. Pendant la première semaine, les patients réalisaient un travail de flexibilité et des exercices cardiorespiratoires. Pendant la deuxième semaine, les patients commençaient un travail de force musculaire. Pendant la troisième semaine, le renforcement musculaire été augmenté avec des exercices d’endurance. Les patients effectuaient des soulevers de charges, ainsi que des exercices de proprioception et de la coordination. Au cours des quatrièmes et cinquièmes semaines, l’intensité des exercices de renforcement augmentait progressivement. L’entraînement cardiovasculaire (marche, course, pédalage) était adapté à chaque patient et individualisé. Le programme était complété par une éducation du patient reposant sur les explications anatomophysiologiques du rachis, les principes du programme, les conseils d’hygiène de vie pendant et après le traitement. Cette éducation se faisait avec la participation de l’entourage familial et médical. La gestion du stress, des facteurs anxiodépressifs et de la douleur se faisait grâce à la visualisation permanente des résultats des paramètres physiques au cours des tests et des entraînements et grâce aux séances de relaxation et de sophrologie. Une fois par semaine, les sujets lombalgiques bénéficiaient d’une consultation avec le psychologue si nécessaire. Des consultations avec l’assistante sociale étaient proposées chaque semaine pour préparer le retour du patient au travail et les conditions de reprise. Une synthèse était organisée chaque semaine pour faire le bilan des progrès du patient.
2.2.3
Protocole expérimental
Notre étude est rétrospective, non randomisée et s’est effectuée en centre de rééducation fonctionnelle. De façon à observer les adaptations et réponses au programme, deux évaluations ont été programmées. La première (T0) a été réalisée le premier jour de l’hospitalisation avant le reconditionnement à l’effort, la seconde (T5sem) se situe à la fin des cinq semaines de rééducation. Pour limiter au maximum les variations biologiques, les tests ont toujours été effectués aux mêmes heures et dans des conditions identiques. L’évaluation initiale a été précédée d’exercices de familiarisation afin que les postures soient correctement réalisées. Les sujets lombalgiques chroniques des deux groupes ont vécu sans distinction, le même programme de RFR.
2.2.4
Paramètres mesurés
2.2.4.1
Données démographiques et cliniques
Pour chaque patient, le médecin rééducateur du centre recueillait les données concernant l’âge, le poids, la taille, l’historique chirurgical, la durée de la lombalgie, la durée de l’arrêt de travail et la consommation de tabac ( Tableau 1 ). L’entretien clinique permettait également de connaître la consommation d’antalgiques et la pratique d’activité physique sportive.
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