“Prehab” is refers to a patient engaging in a rehabilitation process before surgery. There are well-documented factors that affect pain and surgical outcomes. It’s important to implement treatments to address all of them prior to undergoing a procedure with significant risks.
Chronic pain infiltrates every aspect of life. You have pursued endless treatments with promise of relief and you keep being disappointed. Eventually, you may give up any hope of a cure. Most people aren’t anxious to undergo surgery but if it seems like a definitive solution and what else is there to do? Additionally, surgeons are likely to promise a good outcome. Why wouldn’t you choose that option?
Focusing on low back pain, there is a major problem. Fusion surgery for chronic back pain doesn’t work well. The reported success rate is around 25% (1, 2) The data also shows that you can induce or worsen pain after any surgery between 20-60% of the time when operating in the presence of chronic pain. (3) So the chances of making you worse are higher than the chances of success.
Surgery is not a “definitive solution”. It should only be considered for a defined structural problem. That is a lesion that can be defined on an imaging study (MRI, Xray, etc.) with symptoms that match the identified anatomical problem. You can’t fix something you can’t see. LBP is a non-specific symptom and its cause seldom identifiable. I am clear with all of my surgical patients that whatever arm or leg pain I can solve with surgery; it won’t help back or neck pain.
Chronic pain is complex and each human being is unique. There’s a trend in medicine to recommend simplistic solutions to this multi-faceted problem. All the factors that affect pain need to be addressed simultaneously. Almost all treatments offer some benefit but none are effective in isolation. The variables include:
- Physical conditioning
- Life outlook
- Family relationships
You’re the only one who can solve your pain. It’s critical to take control of your care with the medical profession being the source of your information and guidance. If your mindset is, “I just want my pain to go away” or “Fix me” you have almost no chance of meaningful improvement.
What is happening in modern medicine is disconcerting. Providers are almost all on a volume demand where we are given just a few minutes per patient to figure out what’s going on. It is essentially impossible to understand the whole situation in a busy clinic setting, so we are recommending treatments based on limited information. When you show up in a surgeon’s office, they are going to either recommend surgery or not. A paper out of Baltimore shows that less than 10% of surgeons are assessing the known factors that affect the outcomes of surgery, which leads to predictably poor outcomes. (4)
My wake up call
Several years ago my staff noticed that patients who were taking charge of their own care were going through surgery with less pain, better rehab and more consistent long-term outcomes. Historically, my approach was to aggressively address surgical lesions and have the rehab done later. I felt that a person in chronic pain couldn’t tolerate the additional discomfort of an identified structural problem. Most patients did fairly well but a significant number were worse after a well-performed procedure for severe pathology.
About that time, I had a patient with tightly pinched nerves in his lower back. He had both back and leg pain. I tried to work with him for a few months by addressing the above-mentioned common sense variables. He wasn’t buying it. I was clear that surgery would not help the back pain but could help the leg pain. Sure enough the leg pain did disappear after I took the pressure off of the nerves and stabilized the unstable level with a fusion. I would have thought that relieving the leg pain would have made a big difference in his overall quality of life. However, his back pain became much worse and he became incredibly angry. When I reminded him about our pre-operative conversation about not relieving back pain, he went ballistic.
Then I came across scientific studies showing that operating in the presence of chronic pain can induce pain at the new surgical site. I made a decision then that if a given patient didn’t want to learn about the nature of pain and take responsibility for his or her own care, that I wasn’t the surgeon for them. Why would I offer a procedure in a scenario where the success rate was compromised?
Current protocol – prehab
For patients considering elective surgery, we want them first engaging in their own healing process for at least eight to twelve weeks. I encourage them to engage for as long as needed. Some will participate in prehab activities for several years. We want them to be:
- Getting a restful night’s sleep for at least a couple of months. Lack of sleep will induce chronic pain. (5)
- Actively addressing stress to the point where they feel a noticeable decrease in anxiety and frustration.
- Defining and stabilizing pain medications. At a certain dose, narcotics cause more pain by sensitizing the nervous system.
- Becoming more physically active.
- Understand the neurological nature of chronic pain.
- Identify whether they have a structural problem that is amenable to surgery? Do they really understand the risks versus benefits?
- Know that surgery won’t significantly help neck, thoracic or low back pain.
- Looking at harmful habits.
- Stop smoking for at least six weeks prior to a fusion.
- Address eating/ weight
- Address any recreational drugs being used, including excessive alcohol?
All of these issues affect outcomes. It is not a complete list but it does address the core problems.
After implementing a prehab process for all my elective cases, I lost a significant part of my practice. Many patients would see another surgeon, bypass prehab and undergo surgery. But what happened to my practice was unexpected. Not only was I consistently seeing better outcomes, but dozens of patients with severe pathology were cancelling surgery. Their pain had dropped to the point where it was not worth it to them to undergo surgery with its attendant risks.
These outcomes were entirely unexpected. I had no idea how powerful prehab activities could be! It is incredibly rewarding to see a patient become free of pain without exposing him or her to the risks of surgery. I have done surgery for long enough that I am well-aware of the fact there is no such thing as, “simple surgery.” Complications and poor outcomes are always unanticipated and no one (both surgeons and patients) thinks it will happen to them. It’s also enjoyable to see the patients consistently do well when I do perform the operation.
One important caution – this article is not relevant if you are experiencing neurological compromise such as acute leg or arm weakness, loss of balance or bowel and bladder control. There are situations where emergent or urgent surgery is warranted.
I had an older gentleman who was having difficulty walking because his legs hurt and felt rubbery from tightly pinched nerves in his lower back. I wanted to quickly recommend a laminectomy to decompress these nerves and he would have done well. He also couldn’t read English and I thought the chances of him successfully engaging in the DOC process (prehab activities) were limited. I held the line and he began to use the Back in Control website tools utilizing the Google translator. He kept holding off on doing surgery. He came in six months later for what I thought would be his final visit before deciding on surgery. When I asked him if he was ready for surgery, he started laughing. “What are you talking about? I am walking as far as I want and am out dancing a couple of times a week. My leg pain is gone.”
Variations of his story happen several times every week. If someone decides to deeply engage in the healing process, it is almost always just a matter of time before they succeed. It’s the length of time, which is unpredictable.
Spine surgery is risky and I would even argue dangerous. One of my former fellows was devastated recently when a young patient died from a blood clot to his lungs after an elective operation. The surgery had taken seven hours but had gone extremely well. I have seen many unexpected severe complications in my own patients. The decision to undergo surgery is a serious one. Every other possible option should be actively pursued. If your surgeon is not assessing or having someone else look at all the above-mentioned prehab factors, then it is your responsibility to challenge him or her. If there is not a specific identifiable structural problem, the decision for surgery needs to come off of the table. Chronic pain is solvable and surgery when it is appropriate can contribute to a successful outcome. It should never be performed without assessing an addressing all of the factors affecting your pain.
- Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
- Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 190
- Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
- Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
- Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.