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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The number of surgical interventions performed on the lumbar spine due to degenerative osteodiscal problems has significantly increased&#44; fundamentally due to lumbar spinal stenosis&#44; followed by herniated disc and&#44; to a lesser extent&#44; to spondylolisthesis and degenerative disc disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">1&#44;2</span></a> Spinal fusion surgery rates have increased from between 170&#37; and 220&#37; in the United States over the past two decades&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">3&#8211;5</span></a> Although effective&#44; these types of interventions have considerable associated perioperative complications and reoperation rates&#44; and entail significant lengths of hospital stay&#44; and direct and indirect costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">6&#8211;8</span></a> A variable percentage &#40;between 10&#37; and 40&#37;&#41; of patients make suboptimal progress following lumbar discectomy with persistent pain&#44; require reoperation&#44; experience restricted or loss of mobility&#44; and varying degrees disability&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">9&#8211;12</span></a> For these patients postoperative rehabilitation treatment has shown little<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">13</span></a> or no<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">14</span></a> benefit in the medium and long term&#46; Similarly&#44; studies on lumbar fusion surgery that assess the effectiveness of early postoperative rehabilitation have failed to solidly demonstrate significant improvement of either pain or functionality&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is known that an improvement in general health prior to surgery can be associated with better postoperative outcomes and fewer complications for patients who are to undergo various types of surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">19&#8211;22</span></a> This preventive approach that seeks to increase the patient&#39;s functional capacities <span class="elsevierStyleItalic">before</span> surgery&#44; is generically termed &#8220;prehabilitation&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">23&#8211;25</span></a> The concept encompasses a series of physiotherapy and&#47;or cognitive behavioural treatments aimed at improving certain capacities&#44; the patient&#39;s physical status and&#47;or perception of pain&#44; the surgical experience and its consequences&#46; Prehabilitation has proved effective in the context of some trauma surgery&#44; heart surgery and also in the area of oncology&#44; particularly colorectal cancer surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">26&#8211;31</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Likewise&#44; certain types of <span class="elsevierStyleItalic">preoperative education</span> have been proposed as preventive strategies in an attempt to reduce postoperative pain and disability&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">32</span></a> In orthopaedic surgery&#44; however&#44; several systematic reviews have been unable to demonstrate this benefit&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">33&#44;34</span></a> In this regard&#44; Louw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">35</span></a> studied the usefulness of &#8220;neuroscience education&#8221; focussing on the neurophysical and perceptive aspects of pain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Various studies suggest that prehabilitation might be useful in spinal surgery&#44; from the perspective of functional outcomes<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">25&#44;36</span></a> as well as its capacity to shorten hospital stays&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">23</span></a> and even from a financial perspective&#44;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">37</span></a> compared to the traditional postoperative rehabilitation programmes&#46; This approach covers two concepts that are closely related to degenerative spinal surgery&#58; <span class="elsevierStyleItalic">catastrophising</span> or a tendency to consider the progression of the disease to be worse than it really is and&#44; <span class="elsevierStyleItalic">kinesiphobia</span> or irrational fear of physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this paper we perform a review of the literature on the usefulness of prehabilitation for degenerative spinal surgery&#44; we analyse the physical&#44; clinical and practical determinants involved in these treatments and discuss other controversial issues&#44; such as its effectiveness for patients who are obese&#44; have multiple comorbidities or who have catastrophising thoughts&#44; and its possible usefulness as a screening method to select patients who are suitable candidates for surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Development</span><p id="par0030" class="elsevierStylePara elsevierViewall">A search of the PubMed database &#40;<a id="intr0015" class="elsevierStyleInterRef" href="https://www.ncbi.nlm.nih.gov/pubmed/">https&#58;&#47;&#47;www&#46;ncbi&#46;nlm&#46;nih&#46;gov&#47;pubmed&#47;</a>&#41; up until 1 June 2018 using the term &#8220;prehabilitation&#8221; produced 277 entries&#44; which&#44; when combined with the word &#8220;spine&#8221; reduced to 7 papers&#44; of which 2 were excluded because they were not directly related&#46; A subsequent exhaustive search&#44; including articles related to the 5 initial articles&#44; yielded only 7 experimental or review studies&#58; 4 randomised trials&#44;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">18&#44;23&#44;36&#44;38</span></a> one meta-analysis<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> and two ongoing randomised trials&#44;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">39&#44;40</span></a> that directly study the effect of prehabilitation on patients undergoing spinal surgery&#46; The main characteristics of these studies are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definition and <span class="elsevierStyleItalic">rationale</span> of prehabilitation</span><p id="par0035" class="elsevierStylePara elsevierViewall">One of the first references to the term &#8220;prehabilitation&#8221; comes from sports medicine&#46; According to the paper by Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">41</span></a> prehabilitation is the first of the three phases in the care of injured athletes &#40;prehabilitation&#44; rehabilitation and maintenance&#41;&#44; and should ideally be implemented immediately after the injury has occurred&#44; over a period of days or weeks&#46; In turn&#44; this prehabilitation phase would comprise a series of initial care measures&#44; also termed injury first-aid &#40;under the well-known acronym RICE for Rest&#44; Ice&#44; Compression&#44; Elevation&#41;&#44; conditioning or progressive retraining and&#44; finally&#44; the prevention of muscular atrophy by electrostimulation or other techniques&#46; The objective of the prehabilitation phase would be the initial treatment of the injury&#44; keeping the athlete in good cardiovascular condition and minimising the effects of prolonged inactivity or immobilisations due to the injury&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At present&#44; the term &#8220;prehabilitation&#8221; can be defined as a preventive physical and&#47;or cognitive reconditioning strategy whose objective is to improve postoperative outcomes in terms of hospital stay&#44; functional capacity and perioperative complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">24&#44;25&#44;42&#44;43</span></a> This series of actions or programmes can be undertaken ideally during the surgical waiting list period&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> when patients appear to be more receptive to changes in their health behaviour&#44; which might include behaviours aimed at improving their physical condition&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> In general&#44; the physical part of these treatments comprises various specific modalities of physiotherapy and&#47;or strengthening exercises<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">18&#44;23</span></a> for the muscles and joints&#44; or for the body in general&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> Many studies support the theory that improved preoperative physical condition has a favourable impact on functional recovery and on the incidence of perioperative complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">25&#44;44&#44;45</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In short&#44; prehabilitation seeks to increase the patient&#39;s functional capacity before surgery<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">19&#44;23</span></a> with a view to improving their postoperative outcome and their satisfaction with the surgical experience&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> Previous randomised trials<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">18&#44;23&#44;36&#44;38</span></a> have demonstrated that preoperative physiotherapy and education on the perception of pain improve the functional outcomes of patients with radiculopathy&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Types of prehabilitation</span><p id="par0050" class="elsevierStylePara elsevierViewall">Two randomised clinical trials studied the effect of preoperative physiotherapy for patients with degenerative spine conditions&#46; A preoperative physiotherapy programme was used in the paper by Lindb&#228;ck et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">23</span></a> of two sessions per week for 9 weeks of mobilisation and motor control exercises&#44; traction and individualised supervised exercise programmes&#44; together with a behavioural approach to reduce fear avoidance&#44; and increase baseline activity levels&#46; This intervention was complemented with standard information from an orthopaedic surgeon on the details of the intervention&#44; postoperative rehabilitation and recommendations to remain active&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">On the other hand&#44; in the study by Nielsen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">18</span></a> a home programme of preoperative training was used for 6&#8211;8 weeks of 30<span class="elsevierStyleHsp" style=""></span>min daily motor strengthening of the back and abdomen&#44; together with cardiovascular fitness training&#46; The treatment was supervised by a physiotherapist at the start of the programme and 2 weeks after surgery&#46; Likewise the patients were advised to give up smoking and avoid excessive alcohol consumption&#46; Fourteen days before the operation the patients were again informed about the particular characteristics of the intervention&#44; and aspects relating to postoperative mobilisation and rehabilitation&#46; The night before the operation they were given a 200<span class="elsevierStyleHsp" style=""></span>ml nutritional supplement of a high protein drink&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">With regard to cognitive therapy&#44; two randomised studies specifically studied cognitive-behavioural therapy<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">36</span></a> and preoperative education on physiopathological aspects of pain&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">38</span></a> In the trial by Rolving et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">36</span></a> the patients in the intervention group received standard preoperative information from the surgeon in charge&#44; which included information on the intervention&#44; the anaesthetic&#44; medication and postoperative rehabilitation&#46; They also took part in 6 group sessions of 3<span class="elsevierStyleHsp" style=""></span>h &#40;4 sessions before and 2 after the intervention&#41; in which cognitive aspects relating to the perception of pain&#44; coping strategies&#44; ergonomics&#44; return to work&#44; and details of the surgical procedure were discussed&#46; These sessions had a standard content that was adapted according to each patient&#39;s particular needs&#46; They were held by a team of psychologists&#44; occupational therapists&#44; physiotherapists&#44; a social worker&#44; a spinal surgeon&#44; and a patient who had undergone the operation&#44; all of whom had received training through a 2-day course and a specific manual&#44; in order to ensure that the training and advice were uniform&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Neuroscience education was used the paper by Louw et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">38</span></a> a type of cognitive intervention consisting of advice on the decision to undergo the spinal intervention and training on physiology and the functional pathways of the nervous system&#44; neurophysiological bases relating to peripheral nerve sensitisation&#44; effects of surgical experiences and environmental factors associated with this nerve sensitisation&#44; nervous system relaxation&#44; recovery after surgery&#44; scientific evidence for the efficacy of neuroscientific education&#44; and the possibility of raising concerns with the surgeon prior to the operation&#46; It was delivered by physiotherapists on an individual basis&#44; in sessions of an average of 30<span class="elsevierStyleHsp" style=""></span>min&#44; in an informal conversational atmosphere &#40;although following a previously designed checklist designed to ensure uniformity&#41;&#44; using drawings&#44; examples&#44; metaphors&#44; etc&#46;&#44; according to each patient&#39;s needs&#46; An explanatory summary booklet on neuroscientific education was provided that the patients were asked to read at least once before and after the operation&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Effectiveness of prehabilitation</span><p id="par0070" class="elsevierStylePara elsevierViewall">Experimental studies that assess the abovementioned effectiveness of prehabilitation treatment in general provide evidence in favour of its use&#44; although with some nuances&#46; The meta-analysis by Santa Mina et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> &#40;21 studies&#44; a mean 54 patients per study&#44; mean methodological quality moderate &#8211; poor&#41;&#44; with information up until 2011&#44; concludes that prehabilitation seems to have a beneficial effect on hospital stay and therefore&#44; on expenditure&#46; According to the authors&#44; the effect on pain&#44; the rate of complications and postoperative functionality is more controversial&#44; although probably also positive&#46; They recommend using the 6-min walk test to indicate functional capacity&#44; the SF-36 questionnaire to assess quality of life&#44; and length of hospital stay as an indicator of recovery&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The study by Louw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">38</span></a> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>67&#44; randomised&#41; concluded that postoperative pain and functionality were similar in both groups&#44; but the prehabilitation treatment group had a better perception of the surgical experience and fewer health resources were used in the following year&#44; essentially due to performing fewer diagnostic tests&#46; The Danish trial by Nielsen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">18</span></a> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#44; randomised&#41; demonstrated that prehabilitation improved postoperative functionality measured by the Roland-Morris questionnaire&#44; reduced hospital stay and overall satisfaction was better&#44; without a higher rate of complications&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">However&#44; the study by Rolving et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">36</span></a> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>90&#44; randomised&#41;&#44; published in 2015&#44; concluded that cognitive-behavioural therapy produced no significant benefit after one year for patients following lumbar fusion&#44; and although the improvement in disability was faster than in the treated group &#40;since at 3 months the treatment group had significantly improved by a mean 15 points on the ODI&#41; this did not translate into a faster return to work&#46; The authors recommended studying related factors of confusion&#44; stratifying by levels of catastrophising thoughts in particular&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The most recent trial with the highest number of patients&#44; published in 2017&#44; is the Swedish study by Lindb&#228;ck et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">23</span></a> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>197&#44; randomised&#41; performed on patients operated for herniated disc&#44; lumbar stenosis&#44; lumbar listhesis or degenerative disc disease&#46; The group that undertook prehabilitation &#40;exercise programme<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>behavioural therapy&#41; improved compared to the control group on many functionality&#44; physical activity and pain scales&#44; including subjective measures &#40;PROM&#91;Patient Related Outcome Measures&#93;&#41;&#46; However&#44; one year after surgery&#44; only the activity levels were maintained above those of the control group&#44; which suggests that the effect of prehabilitation seems positive but short-lived&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">It is likely that the results of these studies reflect relative uncertainty due to the heterogeneity of the patients and the surgical indications&#44; the different baseline preoperative functionality&#44; the different&#44; but in general elevated&#44; preoperative levels of catastrophising thoughts and the fact that diverse preoperative clinico-epidemiological factors were not taken into account&#44; such as obesity&#44; that affect baseline functionality&#46; Although intuitively it seems that preoperative fitness should improve postoperative functionality in spinal surgery&#44; the scarcity of well-designed studies does not enable a standard therapeutic recommendation yet&#46; A general recommendation when designing prehabilitation studies would be to substratify by levels of comorbidity&#44; catastrophising thoughts and types of surgical indication&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although there is no solid evidence on the effectiveness of physiotherapy before or after spinal fusion surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">46</span></a> the clinical practice guidelines<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">47</span></a> recommend patients should remain active despite their pain&#44; and undertake supervised physiotherapy and cognitive therapy as part of the general principle of multidisciplinary treatment&#46; Despite the evidence on the benefits of physical activity on general health&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">48</span></a> there are several reasons why patients are often immobile preoperatively&#58; a false perception&#44; knowledge or attitude towards physical exercise&#44; fear of movement &#40;<span class="elsevierStyleItalic">kinesiphobia</span>&#41; and the abovementioned catastrophising thoughts&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">46</span></a> Most patients on waiting lists for degenerative spinal surgery have these feelings&#44; therefore preoperative cognitive intervention therapies could be justified in principle&#46; Previous studies on cognitive therapy in patients undergoing lumbar fusion support the beneficial effect of these treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">15&#44;17</span></a> Similarly&#44; the literature provides some evidence in favour of this therapy undertaken preoperatively&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">18&#44;23&#44;36</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Several studies and meta-analyses recommend cognitive-behavioural therapy for patients with chronic low back pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">49&#44;50</span></a> Although various systematic reviews published by orthopaedic surgeons recommend starting interventions &#40;information and&#47;or exercises&#41; before surgery<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">51&#44;52</span></a> and calculate complications from the perspective of the surgeon as well as the patient&#44;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">53</span></a> there are still no definitive data on the effectiveness of rehabilitation strategies before spinal surgery&#46; Both age and sex seem to influence the perception of the surgical experience&#44; as suggested in the study by Papanastassiou et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">54</span></a> which stated that elderly women following elective spinal surgery seem to have lower levels of satisfaction with the procedure in general&#44; and with pain control&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">54</span></a></p></span><span id="sec9025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect9045">Physical and cognitive determinants of prehabilitation&#58; multiple comorbidities&#44; obesity and catastrophising thoughts</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although the effect of prehabilitation has not been specifically studied in the subpopulation on elderly people with comorbidities&#44; a beneficial effect is likely&#44; at least in its effect on improving general health status before any intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">55</span></a> When analysing this association it has been suggested that determinants should be considered such as age&#44; Charlson comorbidity index<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">56</span></a> or others&#44; such as the Vulnerable Elders Surgical Pathways and Outcomes Assessment &#40;VESPA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">57</span></a> Even a history of at least one fall in the 6 months before a major intervention seems to predispose to an increased incidence of postoperative complications&#44; readmission at 30 days&#44; and discharge from hospital to a care facility&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">58</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The study by Makary et al&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">59</span></a> uses the concept of preoperative <span class="elsevierStyleItalic">frailty</span>&#44; measured by a validated scale that includes varying degrees of weakness&#44; weight loss&#44; fatigue&#44; low physical activity and slow walking speed&#46; According to this study&#44; the degree of preoperative frailty correlates with an incidence of postoperative complications&#44; lengths of hospital stay and discharge from hospital to an assisted care facility double or triple that of patients not considered frail&#46; The authors conclude that a standardised definition of frailty could help doctors and patients to make more informed decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">59</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Obesity and sedentary lifestyles are known risk factors for many metabolic and osteoarticular conditions&#44; including degenerative spinal disease&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">60</span></a> Losing weight prior to surgery could be beneficial from an anaesthetic point of view in terms of the incidence of infections and deep vein thrombosis&#44; although it is not clear whether it affects functional outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">61</span></a> Intuitively and reasonably it would seem that prehabilitation might benefit obese patients by means of weight loss programmes supported by physical therapy and&#47;or cognitive-behavioural therapy&#46; However&#44; the current literature provides no conclusive data in this regard&#46; The recent meta-analysis by Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">62</span></a> &#40;10 cohort studies with 29&#44;748 patients&#41; shows that obesity and excess weight are obvious risk factors for lower back pain for both sexes&#44; especially obese women &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#8211;4&#41;&#44; and that maintaining a suitable weight &#40;termed healthy body weight&#41; helps to prevent lower back pain&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Catastrophising thoughts and kinesiphobia are very prevalent determinants in the management of patients with degenerative spinal disease&#46; Behaviours of excessive fear of physical exercise are commonly seen in these patients based on the erroneous belief that physical activity will necessarily make symptoms worse&#46; Sometimes&#44; doctors themselves condition patients&#8217; attitudes to a degree&#44; especially when they hear pessimistic comments &#40;&#8220;your back is in a terrible state&#8221;&#41; based on radiological reports with descriptions <span class="elsevierStyleItalic">loaded</span> with non-serious conditions&#44; of doubtful clinical significance or simply not unusual given the age of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">63&#44;64</span></a> Similarly&#44; it is not rare to find patients who have been unnecessarily alarmed and advised that they require immediate surgery or risk serious and irreversible sequelae &#40;&#8220;&#8230; I was told that if I didn&#8217;t have an operation I would end up in a wheelchair&#8230;&#8221;&#41;&#46; Because it is widely known that the natural history of degenerative spinal disease is relatively benign &#40;especially as regards lumbar disc herniation&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">65</span></a> unnecessarily alarming patients is irresponsible and can occasionally hide a true conflict of interests&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Relieving the emotional stress involved in chronic pain and <span class="elsevierStyleItalic">dedramatising</span> are crucial in the management of this disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">5</span></a> Catastrophising thoughts and kinesiphobia must be combated with honest education&#44; and advice<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">15</span></a> and cooperation between specialists&#44; especially at the level of primary medicine&#44; since back pain is one of the commonest reasons for consulting general practitioners&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">66</span></a> The abuse of opioid analgesic drugs and neuromodulators&#44; the aggressiveness of invasive treatment for chronic pain and the flourishing of chronic pain units could in part be a consequence of this pessimistic and catastrophising view of degenerative spinal disease&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">5</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The randomised trial by Monticone et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">15</span></a> and others<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">67&#44;68</span></a> demonstrated the beneficial effect of cognitive-behavioural therapy in improving the specific self-administered scales that evaluate catastrophising thoughts &#40;Pain Catastrophising Scale &#91;PCS&#93;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">69</span></a> kinesiphobia &#40;Tampa Scale for Kinesiophobia &#91;TSK&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">70</span></a> and quality of life &#40;Short-Form Health Survey &#91;SF-36&#93;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">71</span></a> However the effect of prehabilitation on these items has not yet been studied prospectively&#46; It is reasonable to believe that there are differences in the perception of catastrophising and kinesiphobia according to cultural&#44; educational&#44; social and age-related aspects&#44; which must be taken into account when designing future studies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Controversial issues</span><p id="par0140" class="elsevierStylePara elsevierViewall">Given the shortage and heterogeneity of prospective studies that assess prehabilitation treatment and its effect on the functional outcomes of patients following degenerative spinal surgery&#44; its true effectiveness is really not known&#46; The supposed savings in costs if it is used might be influenced by intermediate variables &#40;reduced complications&#44; spontaneous improvement of pain as part of its own natural course&#41;&#44; which in turn are affected by other factors&#44; including the surgical waiting list itself&#46; Randomised studies that are currently ongoing &#40;in patients scheduled for lumbar stenosis surgery<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">39</span></a> and those to be operated due to radiculopathy<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">40</span></a>&#41; could reinforce the beneficial effect of prehabilitation or possibly question its efficacy&#46; In our environment&#44; a priori&#44; there seem to be no ethical or legal restrictions or impediments to undertaking these types of studies&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">An interesting question is whether prehabilitation could serve as preoperative screening&#44; i&#46;e&#46;&#44; as a method for selecting patients who are better candidates for surgery&#46; Some authors suggest that physical therapy could be as effective as decompression surgery in some cases of spinal stenosis in a sample of patients who were candidates for surgery&#44; and that prehabilitation could be considered a method of psychosocial screening in selecting patients suitable for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">72</span></a> More prospective studies&#44; stratified by disease&#44; age and comorbidities are required to clarify this point&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Finally&#44; we also do not know whether prehabilitation should differ according to the patient&#39;s type of work &#40;physical fitness&#41; or the age&#47;mental or psychological status of the patient&#46; Future studies could clarify whether prehabilitation treatment should focus more on physical aspects than cognitive aspects or vice versa&#44; according to clinical covariables&#46; Given the enormous prevalence of this disease group&#44; if eventually the efficacy of prehabilitation is unequivocally demonstrated&#44; it will be relevant to discuss which specialist &#40;spinal surgeon&#44; physiotherapist&#44; psychologist&#44; anaesthetist&#44; general practice&#44; etc&#46;&#41; should coordinate treatment&#44; and who should fund this therapy&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "identificador" => "xres1184285"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Development"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Definition and rationale of prehabilitation"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Types of prehabilitation"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Effectiveness of prehabilitation"
        ]
        9 => array:2 [
          "identificador" => "sec9025"
          "titulo" => "Physical and cognitive determinants of prehabilitation&#58; multiple comorbidities&#44; obesity and catastrophising thoughts"
        ]
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          "identificador" => "sec0030"
          "titulo" => "Controversial issues"
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          "titulo" => "Conflict of interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-10-03"
    "fechaAceptado" => "2018-11-19"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1104629"
          "palabras" => array:5 [
            0 => "Prehabilitation"
            1 => "Physiotherapy"
            2 => "Cognitive-behavioural therapy"
            3 => "Catastrophising"
            4 => "Lumbar surgery"
          ]
        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Prehabilitaci&#243;n"
            1 => "Fisioterapia"
            2 => "Terapia cognitivo-conductual"
            3 => "Catastrofismo"
            4 => "Cirug&#237;a lumbar"
          ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgery for lumbar degenerative pathology&#44; although effective&#44; results in suboptimal outcome and degrees of disability in a relevant proportion of patients&#46; Postoperative rehabilitation has failed to demonstrate efficacy in the mid and long term&#46; So-called &#8220;prehabilitation&#8221; &#40;physiotherapy and&#47;or cognitive-behavioural therapy&#41; focuses in augmenting patients&#8217; functional capacities before surgery by improving their physical condition and their perception of pain&#44; surgical experience or its consequences&#46; Several studies suggest that prehabilitation improves postoperative outcome&#44; shortens hospital stay and may reduce costs compared to classic postoperative rehabilitation&#46; However&#44; its true effect seems to be influenced by factors like obesity&#44; co-morbidity and&#44; especially&#44; by a wrong perception of the natural history of this pathology in terms of catastrophising and kinesiphobia&#46; In this paper we describe the concept of prehabilitation&#44; review the literature&#44; and discuss the role of some clinical conditionings involved&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a de columna lumbar degenerativa&#44; aunque efectiva&#44; produce resultados sub&#243;ptimos y cierto grado de discapacidad en un porcentaje relevante de pacientes&#46; El tratamiento rehabilitador postoperatorio no ha demostrado utilidad a medio y a largo plazo&#46; La denominada &#171;prehabilitaci&#243;n&#187; &#40;tratamientos f&#237;sioter&#225;picos y&#47;o cognitivo-conductuales&#41; busca aumentar las capacidades funcionales del paciente antes de la intervenci&#243;n mejorando el estado f&#237;sico y la percepci&#243;n del dolor&#44; de la experiencia quir&#250;rgica o de sus consecuencias&#46; Diversos estudios sugieren que la prehabilitaci&#243;n mejora la funcionalidad postoperatoria&#44; acorta la estancia hospitalaria y podr&#237;a ahorrar costes frente a la rehabilitaci&#243;n postoperatoria cl&#225;sica&#46; Sin embargo&#44; su efecto real parece influenciarse de variables como la obesidad&#44; comorbilidades y&#44; especialmente&#44; una err&#243;nea percepci&#243;n de la historia natural de estas enfermedades&#44; en forma de catastrofismo y cinesifobia&#46; En este trabajo se describe el concepto de prehabilitaci&#243;n&#44; se revisa la literatura al respecto y se discute el papel de diversos condicionantes cl&#237;nicos involucrados&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Delgado-L&#243;pez PD&#44; Rodr&#237;guez-Salazar A&#44; Castilla-D&#237;ez JM&#46; &#171;Prehabilitaci&#243;n&#187; en cirug&#237;a de columna degenerativa&#58; revisi&#243;n de la literatura&#46; Neurocirugia&#46; 2019&#59;30&#58;124&#8211;132&#46;</p>"
      ]
    ]
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">EEG&#58; electroencephalogram&#59; EQ-5D&#58; <span class="elsevierStyleItalic">EuroQol-5D</span>&#59; EQ-VAS&#58; EuroQol-visual Analogue Scales&#59; FABQ-PA&#58; <span class="elsevierStyleItalic">Fear-Avoidance Beliefs Questionnaire-Physical Activity</span>&#59; HADS&#58; <span class="elsevierStyleItalic">Hospital Anxiety and Depression Scale</span>&#59; ODI&#58; Oswestry Disability Index&#59; PROM&#58; Patient Related Outcome Measures&#59; RHB&#58; rehabilitation&#59; SES&#58; <span class="elsevierStyleItalic">Socio Economic Status</span>&#59; SF-36&#58; <span class="elsevierStyleItalic">Short-Form Health Survey</span>&#59; VAS&#58; Visual Analogue Scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author &#40;year of publication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Commentary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lindb&#228;ck et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">23</span></a> &#40;2017&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Swedish randomised trial&#46;<br><span class="elsevierStyleItalic">PREPARE &#40;PREhabilitation&#44; Physical Activity and exeRcisE&#41;</span>&#46;<br>Single-blinded&#44; two-arm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>197 consecutive patients&#44; ages&#58; 25&#8211;80 years&#46;<br>Prehabilitation&#58; 99 patients&#46;<br>Control&#58; 98 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients scheduled for herniated disc&#44; lumbar stenosis&#44; spondylolisthesis or degenerative disc surgery&#46;<br>Randomised to presurgical physiotherapy &#40;9 weeks with specific physical exercises and behavioural therapy to reduce avoidance behaviours and increase activity levels&#41; or to standard information&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The prehabilitation group obtained better ODI&#44; VAS for lower back pain&#44; EQ-5D&#44; EQ-VAS&#44; FABQ-PA&#44; SES and HADS and activity levels than the control group&#46; Improvements were small but clinically significant&#46; Almost all the PROM improved&#46;<br>After the surgery&#44; only the activity levels remained above those of the control group &#40;after one year of follow-up&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preoperative prehabilitation reduces pain and prevents psychological impairment while improving quality of life due to physical activity levels&#44; although only the improvement in physical activity levels was maintained after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rolving et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">36</span></a> &#40;2015&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Danish randomised trial&#46;<br>Single-blinded&#44; two-arm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>90&#46;<br>Ages&#58; 18&#8211;64 years&#46;<br>Prehabilitation&#58; 59 patients&#46;<br>Control&#58; 31 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Danish speaking patients scheduled for surgery due to degenerative disease&#44; spondylolisthesis grades I&#8211;II&#44; maximum 3 level spinal fusion&#46;<br>Randomised to standard information &#40;control&#41; or to information<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>cognitive-behavioural therapy &#40;6 3h sessions&#41;&#46; Both received postoperative RHB 12 weeks after the surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At one year of follow-up there were no significant differences between both groups in the ODI&#46; The behavioural treatment group achieved a significant early &#40;at 3 months&#41; reduction in the ODI of &#8722;15 points&#44; which was maintained throughout the year&#46; After follow-up no differences were identified on the catastrophising&#44; disability&#44; lower back and radicular pain&#44; and return to work scales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cognitive-behavioural therapy did not produce any significant benefit at one year for patients following lumbar fusion&#46; Although reduced disability was achieved faster in the treatment group&#44; this did not translate to a faster return to work&#46; They recommend that patients with elevated levels of catastrophising should be studied separately&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Louw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">38</span></a> &#40;2014&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">North American multi-centre randomised trial&#46;<br>Single-blinded&#44; two-arm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>67&#46;<br>Mean ages both&#58; 50 years&#46;<br>Prehabilitation&#58; 32 patients&#46;<br>Control&#58; 35 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients scheduled for lumbar surgery due to radiculopathy &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>65&#41;&#46;<br>Randomised to standard preoperative education &#40;control&#41; or to standard education<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 session of neuroscientific education on pain delivered by a physiotherapist and information booklet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At one year of follow-up there were no differences between the groups in terms of lower back pain&#44; sciatica or function&#46; The treatment group achieved higher scores for the categories on surgical experience&#46; Similarly&#44; the treatment group required 45&#37; less expenditure in the year of follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Although functionality and level of pain were similar in both groups&#44; the perception of surgical experience was better in the treated group&#46; They also used fewer health resources &#40;treatments and diagnostic tests&#41; in the following year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nielsen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">18</span></a> &#40;2010&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Danish randomised trial&#46;<br>Single-blinded&#44; two-arm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#46;<br>Ages&#46;<br>Prehabilitation&#58; 28 patients<br>Control&#58; 32 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients scheduled for spinal surgery due to radiculopathy or degenerative back pain&#46;<br>Randomised to prehabilitation &#40;2 months before&#44; intensive exercise programme and optimised analgesia and high protein drink 24<span class="elsevierStyleHsp" style=""></span>h prior to surgery&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>early RHB &#40;self-administered epidural analgesia&#44; intensified mobilisation&#41; or standard treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At the time of surgery the treatment gave better functionality measured by the Roland Morris questionnaire&#46; After the surgery&#44; the treated group achieved better recovery earlier &#40;1&#8211;6 vs 3&#8211;13 days&#41; and a shorter hospital stay &#40;5 vs 7 days&#41;&#46; There were no differences in complications&#44; lower back pain or sciatica and quality of life&#46; Patient satisfaction was higher in the treated group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prehabilitation together with early postoperative RHB improved outcomes and shortened hospital stay&#46; The treated group did not have more complications&#44; postoperative pain and the level of satisfaction improved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Santa Mina et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a> &#40;2014&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systematic review and meta-analysis&#46;<br>Review of the period 1950&#8211;2011&#46;<br>The effect of total-body prehabilitation in many types of interventions of diverse specialities&#44; not only spinal surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4597 citations were identified&#46;<br>Due to the heterogeneity&#44; only papers that included data on hospital stay were considered for the meta-analysis&#46; The data from 21 studies were used&#46;<br>Mean of 54 participants per study&#46; Moderate or poor methodological quality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Compared with standard treatment&#44; most studies on total body prehabilitation improved postoperative pain&#44; hospital stay and physical functionality&#46; There was no obvious improvement in health-related quality of life or aerobic fitness&#46; The meta-analysis showed a slight but significant reduction in hospital stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prehabilitation seems to have a beneficial effect on length of hospital stay &#40;especially more for heart surgery&#41; and therefore on expenditure&#46; It might be of postoperative benefit in terms of pain&#44; complications and functionality&#46; Consider relevant measures&#58; 6-min walk-test for functional capacity&#44; SF-36 for quality of life and length of hospital stay for recovery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Marchand et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">39</span></a> &#40;2015&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ongoing randomised trial &#40;<a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="ctgov:NCT02258672">NCT02258672</a>&#41;&#46;<br>Canadian&#46;<br>Randomised&#44; single-blinded&#44; two-arm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients undergoing elective surgery for lumbar stenosis&#46;<br>Randomised to a supervised preoperative RHB programme of 6 weeks or standard preoperative management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The treatment will comprise 3 sessions per week of muscle strengthening&#44; spinal stability and cardiovascular fitness&#44; of increasing intensity according to the participant&#46; Primary outcome measures&#58; lower back pain and disability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline assessments were undertaken&#44; at the end of the preoperative treatment&#44; at 6 weeks&#44; 3 and 6 months postoperatively&#46; This paper will serve as a preliminary study for another&#44; larger scale study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ickmans et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">40</span></a> &#40;2016&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ongoing Belgian randomised trial&#46;<br>Multicentre&#44; randomised&#44; single-blinded&#44; two-arm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients undergoing surgery for lumbar radiculopathy&#46;<br>Randomised to neuroscientific education about pain &#40;in two individual sessions&#44; one preoperative and the other postoperative<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>information booklet&#41; or standard preoperative treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Primary outcome measures&#58; self-reported pain and endogenous pain modulation &#40;including simultaneous cortical activation via EEG&#41;&#46; Secondary&#58; function&#44; return to work&#44; postoperative medical expenditure&#44; satisfaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline measurements will be made&#44; at 3 days and 6 weeks after surgery&#46; Follow-up for 24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Description of intervention studies that evaluate prehabilitation programmes for degenerative spinal surgery&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:72 [
            0 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "1"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                            2 => "B&#46;I&#46; Martin"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2010.338"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
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            1 => array:3 [
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:3 [
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                            0 => "B&#46; Str&#246;mqvist"
                            1 => "P&#46; Fritzell"
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00586-013-2758-9"
                      "Revista" => array:6 [
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            2 => array:3 [
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              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "discussion 1446-1447"
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                    0 => array:2 [
                      "titulo" => "United States trends in lumbar fusion surgery for degenerative conditions"
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                        0 => array:2 [
                          "etal" => false
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                    0 => array:2 [
                      "titulo" => "Spinal fusion in the United States&#58; analysis of trends from 1998 to 2008"
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                          "etal" => false
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