Phone counseling reduces pain, disability after back surgery

The phone calls, designed to enrich standard pre- and post-operative care by reinforcing the value of sticking with physical therapy and back-strengthening exercise regimens, are a relatively inexpensive and simple intervention that can maximize surgical outcomes for the hundreds of thousands of Americans who undergo spinal surgeries every year, the investigators say.

A report on the findings of the federally funded research is published online March 28 in the journal Archives of Physical Medicine and Rehabilitation.

"Phone counseling appears to be an easy, low-cost strategy that yields meaningful results by improving patient engagement in physical therapy and at-home exercise programs that are so vital for their recovery," says study lead investigator Richard Skolasky Jr., Sc.D., associate professor of orthopedic surgery at the Johns Hopkins University School of Medicine. "Approaches like this one will play an important role in improving patient outcomes and reducing health care spending in an era when hospitals are increasingly being judged on the quality rather than quantity of care they provide."

The new study was prompted, Skolasky says, by previous research showing that many back surgery patients skimp or give up on physical therapy and home exercises. Up to 40 percent continue to experience post-operative pain mainly due to loss of muscle tone after years of suffering from back pain and reduced mobility of the spine. The problem is often compounded by surgical cuts made into the deep muscle tissue during back operations.

The Johns Hopkins study involved 122 patients ages 46 to 72 who underwent surgery at The Johns Hopkins Hospital between 2009 and 2012 to correct spinal stenosis, a condition marked by degeneration of the spinal bones and painful compression of the spinal cord. The disease is the most common reason for spinal surgery and is expected to affect more than 60 million Americans by 2025.

All patients were prescribed either home exercise programs or physical therapy to help speed recovery. About one-half of them also received a series of phone counseling sessions from a trained spinal surgery counselor to discuss the importance of exercise in their recovery. The first and most detailed phone session took place a few weeks before the patients had their surgeries. Two follow-up "booster" sessions took place at six weeks and three months after the operation.

Overall, patients who got such phone calls participated in physical therapy and home exercise at higher rates and had less pain and less disability six months after their surgery, compared with the standard-approach group. Six months after surgery, 74 percent of patients who received phone counseling experienced significant improvements on standard measures of physical functioning and self-reported measures of pain, compared with 41 percent of those who did not receive phone calls. The differences in functional outcomes between the two groups mirrored differences in physical therapy attendance rates and home-exercise completion rates within each group.

"Modern orthopedic science has made great strides in surgical techniques to correct spinal deformities and achieved significant progress in developing physical therapies that boost the benefits of surgery, but we haven't been all that good at motivating and engaging patients to partake in such post-surgical recovery programs," says co-investigator Stephen Wegener, Ph.D., associate professor of physical medicine and rehabilitation at Johns Hopkins. "The findings of our research suggest we may have found a way to add that missing ingredient that draws patients to be more active participants in their physical rehabilitation and recovery."

The researchers note the phone conversations were modeled on well-established motivational interview techniques that engage patients in their care and make them active participants in their recovery. This type of interactive counseling has been shown to improve diabetes self-care and management of high blood pressure, and to increase safe-sex practices.

"The calls are intended to help patients become more self-aware of their own perceptions about care, and are more of a collaboration between counselor and patient than one-way instruction," Skolasky says.

Although the phone counseling sessions significantly boosted patient engagement rates, one-third of patients remained resistant to intervention, the study results found. The most prevalent factors in their disengagement, the investigators say, were low self-confidence in the ability to perform the exercises or get to a physical therapy session, fear of movement, and concern about pain management.

These hurdles -- whether real or perceived -- should be on every clinician's radar, the investigators say, and must be addressed head on in order to improve patient engagement.