Developing a Pre-Surgical Rehabilitation Intervention for Individuals with Symptomatic Lumbar Spinal Stenosis

Abstract

Symptomatic lumbar spinal stenosis (SLSS) is a common cause of pain and disability among older adults and is the most common indication for lumbar spine surgery in older adults. However, one-third of patients do not experience clinically important improvements in pain or disability after surgery. This thesis included 4 studies with an overarching aim of understanding the perioperative experience of SLSS patients and developing a patient-centred prehabilitation program to improve post-operative outcomes. The first study aimed to understand SLSS patient’s surgical decision-making. We conducted qualitative interviews (n=35) and used inductive phenomenology to identify five themes: previous experiences with non-surgical management, worrisome symptoms impacting functionality, perception of surgery as a final course of action, post-surgical hopes/expectations, and having a social support network. The second study aimed to understand the unmet needs and expectations for the management of SLSS among the same participant group. We identified four themes: the complexity of navigating the healthcare system, the need for strengthened perioperative management, the absence of peer support as a desired opportunity, and difficulty navigating post-operative recovery without healthcare provider support. The insights from the qualitative studies informed the development of an 8-week, patient-centered prehabilitation intervention, which included principles of cognitive behavioural therapy, motivational interviewing, graded activity, education and peer support. A feasibility randomized controlled trial (RCT) comparing the prehabilitation to minimal intervention was conducted, including outcomes of recruitment rate, adherence, program satisfaction, attrition, and barriers and facilitators. There was a 57% referral acceptance rate and challenges with recurrent and attrition due to early surgery, meaning that pilot feasibility criteria were not met. However, participants that completed the intervention reported high satisfaction with care, although this should be interpreted with caution given the small sample size. Parallel to the RCT, we conducted a longitudinal qualitative study (semi-structured interviews before and after the intervention and 3 months after surgery). We identified four recovery trajectories among participants: sedentary struggle, dynamic recovery, dynamic struggle, and dynamic resilience. These trajectories highlighted the role of changing attitudes and behaviours towards exercise and physical activity in recovery. The findings of this thesis suggest the need for targeted management pathways for SLSS, emphasizing the importance of integrating a psychosocial approach.