INTRODUCTION 
Approximately 230 million surgical procedures are performed annually worldwide. Surgery is acknowledged as one of the most frequent causes of chronic pain in patients attending pain clinics. Access to adequate pain management is declared a human right by the International Association for the Study of Pain (IASP), but what the non-pharmacological pain management should contain before surgery is not clear. The phase before surgery is suggested to be the ideal time to prepare patients for an optimal outcome from surgery by carrying out prehabilitation. This study investigated whether a person-centered non-pharmacological prehabilitation program based on a cognitive-behavioral approach reduces disability and improves functioning after lumbar fusion surgery more than does conventional care.  

METHODS 
Patients scheduled for lumbar fusion surgery were recruited from two private spine clinics and one university hospital in Gothenburg, Sweden. The patients were a subgroup of individuals with CLBP, characterized by the combination of motion elicited (often called mechanical), localized, clinically provocable pain, with corresponding (i.e. the same region) radiologically demonstrated degenerative changes (i.e. disc height reduction and facet arthrosis in varying combination) in one or a few of the lumbar intervertebral segments. The patients were randomized into either an active intervention group or to a control group. The active intervention utilized a person-centered approach over 5 sessions (4.5 hours in total) and focused on promoting physical activity and targeting pain-related fear factors before surgery. The control group received conventional preoperative care. 
The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on seven occasions up to 1 year postoperatively. A linear mixed model was used to analyze the change scores of each outcome. 

RESULTS 
No statistically significant difference between groups was found on the primary outcome (disability) over time (baseline to 1 year). Among secondary outcome measures, a statistically-significant interaction effect (“Group x Time”) was seen for EQ-5D. Minimally important changes over time were found in almost all outcomes in each group separately. Both groups reached a stable plateau of change in primary and secondary outcomes by 8 weeks post-operatively. In the patient specific functioning scale (PSFS) the improvement continued to 1 year. 

DISCUSSION 
A prehabilitation program leads to clinically important changes in pain variables (pain intensity and fear-avoidance variables), and does not lead to any negative side effects. 
The principles of non-pharmacological pain management needs to be incorporated in surgical context, such as before surgery in a prehabilitation program. 
Trial registration: Current Controlled Trials ISRCTN17115599.

A NON-PHARMACOLOGICAL PREHABILITATION PROGRAM BASED ON A COGNITIVE-BEHAVIORAL APPROACH FOR PATIENTS SCHEDULED FOR LUMBAR SURGERY - A ONE YEAR FOLLOW-UP OF A RANDOMIZED CONTROLLED TRIAL