Effect of feedback health education on postoperative rehabilitation of patients with lumbar disc herniation:a cluster randomised trials

Rong Fan,Li-Ang Fan,Gui-Ying Gao,Min Zhang and Gui-Hong Yan

Abstract—Aims and objective:A theoretical model based on guided postoperative rehabilitation with feedback was developed for patients with lumbar intervertebral disc protrusion to explore the effects of feedback-based health education.Patients were assessed in terms of disease knowledge,general selfefficacy,medical behaviour,and the Oswestry disability index(ODI).During postoperative rehabilitation,nursing staff provided health education regarding lumbar intervertebral disc protrusion.Design:The CONSORT 2010 statement extension for cluster randomized trials checklist (Campbell et al.,2012)was used to guide reporting outcomes (File S1).Methods:The methods were based on previous research on the feedback method of health education.A cluster randomized controlled trial design was used.From March 2019 to January 2020,patients who underwent spinal surgery at a first-class tertiary hospital were enrolled,and 76 met the inclusion criteria for lumbar disc disease (lumbar disc herniation,LDH).Patients were divided into an experimental group and a control group,with 38 patients in each group.Feedback-based health education was conducted for the experimental group,and routine health education was provided for the control group.Disease knowledge,general self-efficacy,compliance behaviour,and ODI scores were compared between the two groups.The intervention effect was compared between groups by means of t tests.SPSS 23.0 was used for statistical analysis,and P <0.05 was considered statistically significant.The research was reported according to CONSORT statement.Results:1.Comparison of baseline data between the two groups before the intervention.Before the intervention,there was no statistically significant difference between the two groups in terms of general demographic data,disease-related data,disease knowledge,general self-efficacy,compliance behaviour,or ODI(P>0.05).2.Comparison of relevant indicators between the two groups of patients before and after the intervention.(1)One,four and 12 weeks after surgery,the disease knowledge,general self-efficacy and postoperative compliance behaviour of the experimental group were significantly higher than those of the control group(P<0.05).(2)At 1,4 and 12 weeks after surgery,the ODI of the experimental group was significantly lower than that of the control group (P <0.05).Conclusions:Feedback-based health education is conducive to improving disease knowledge,general self-efficacy and compliance behaviour and reducing ODI scores in patients with LDH.Relevance to clinical practice:This study provides nurses worldwide with a reference for health education during postoperative rehabilitation for lumbar disc herniation.

Keywords—Lumbar disc herniation,Feedback method,Health education,Nursing,Functional exercise

I.INTRODUCTION

Lumbar disc herniation (LDH) is a herniation or degeneration caused by ruptured annulus degeneration,a nucleus pulposus between vertebra that stimulates the nerve root,or horsetail nerve compression.The common symptoms are waist and leg pain,tingling,and abnormalities in muscle strength of the lower limb.Lumbar disc disease is a common disease and frequently treated by spine surgery [1–3].Most of the patients are young and middle-aged,with more males than females [4].The protrusion of lumbar intervertebral discs is widely prevalent worldwide,greatly harming people’s health[5,6].Since the onset of the disease is relatively slow,the initial symptoms are hidden and can be relieved at rest,so people ignore it,while the disease becomes increasingly serious[7].

In foreign countries,the incidence of LDH has reached 15%～30%[8].Statistics from the Ministry of Health of China show that the incidence of LDH is approximately 5%～10%,which is relatively high and rising [9].At present,most clinicians focus on improving surgical methods and often ignore postoperative functional recovery.Surgery is successful in only half of patients with LDH.Positive and effective nursing is an important means of assuring the effect of surgery.Nursing methods have a great influence on the operative effect,and nurses can take effective measures to help patients perform postoperative rehabilitation exercises.This has a very important role in the functional recovery of patients [10,11].Growing body of evidence suggests[12]that improving health knowledge leads to fewer disease,so this research uses the feedback method of health education.The American Medical Association has suggested that doctors use the feedback method of health education,which entails using simple language and auxiliary education tools to provide patients with health information and also requires patient repeat information In your own words[13].The national quality forum[14]aslo recommended using the feedback method of health education,as it is one of the 34 kinds of safe and effective health education.Therefore,this study will conduct health education for patients from China according to the steps of the feedback method and the main contents of this study were to observethe changes in patients’ disease knowledge,general self-efficacy,compliance behavior,and Oswestry disability Index (ODI).

The feedback method is also known as feedback teaching and closing the loop[15,16].Feedback-based health education is a patient-centred,interactive dialogue mode between nursing staff and patients [17],a process that is continually repeated when information is provided[18].

II.STUDY DESIGN THIS STUDY IS AN EXPERIMENTAL STUDY

A.Subjects

Patients who underwent surgical treatment for lumbar disc herniation in a first-class tertiary hospital from March 2019 to January 2020 were selected as the research subjects.

1) Inclusion criteria:(1) Patients who met the diagnostic criteria of the North American Spine Society (NASS)Evidence-Based Clinical Guidelines [19] (2) Above 18 years of age;(3) Good communication and understanding ability;(4)Informed consent and voluntary participation.

2) Exclusion criteria:(1) Lumbar malignant tumours,lumbar tuberculosis and osteoporosis;(2)lumbar spondylolisthesis with lumbar intervertebral canal stenosis;(3) insufficiency of organs and cardiovascular and cerebrovascular diseases;and(4)mental health diseases.

3) Sample size calculation:The sample size calculation was based on the comparison of two sample means:n=2×[(Zα+Zβ)×(σ/δ)]2.The main outcome index of this study was the ODI of LDH patients.According to the literature [11],σ=4.896 and δ=4.69,and the following values were used:significance level α=0.05 and β=0.1.According to the table,Z α/2=1.96 and Z β=1.282,so n1=n2=2[(1.96+1.282) ×(4.896/4.69)]2≈25(cases) were considered necessary;thus,38 cases were included in each group,for a total of 76 cases,considering a 20%loss rate.

4) Grouping method

5)One graduate student,who enrolled participants,adopted the feedback method to conduct health education for LDH patients,answered patients’ questions in time,and dealt with problems in time if found.An undergraduate student Who generated the random allocation sequence.

A professor,who assigned participants to intervene,plays an overall role in providing guidance and responsibility for the successful implementation of clinical health education.In order to provide team members with unified training in health education through response.

6) Research tools:

a) General data:The content includes general demographic and sociologic data such as sex,age and education level,as well as basic information on diseases.

b) LDH knowledge questionnaire:The LDH knowledge questionnaire was prepared by Shi(2016)[20]and had a total of 12 items.The questionnaire was scored on a 5-point Likert scale,with the full score being 60 points.The higher the score,the greater the patient’s knowledge mastery was.The content validity of the knowledge questionnaire was 0.96,and Cronbach’s α coefficient was 0.80.

c) General self-efficacy scale:

d)Questionnaire on the compliance behaviour of LDH patients The questionnaire on the compliance behaviour of LDH patients was prepared by Shi Yixin,a researcher.The questionnaire was scored by Likert level 5,with a total score of 90 points.The higher the score,the better the compliance behavior of patients.The content validity of the questionnaire was 0.98,and Cronbach’s α coefficient was 0.84.The questionnaire included questions on functional exercise,activities,diet,daily living,review,etc.

e) Oswestry disability index (ODI) scale:This scale is widely used in China and internationally,and in the field of spinal medicine,it is recognized as the gold standard for evaluating curative effects and function [23].The scale was compiled in 1980 by Fairbank and colleagues and has been revised since [24–26];it was first used in China after it was adapted by[27].The Likert 6-level score was used,and the score of each item ranged from 0 to 5,and the total score was 45.The higher the score,the worse the lumbar function.The content validity of this scale was 0.88,and the Cronbach S α coefficient was 0.91,The scale is used to evaluate the efficacy of surgical treatment and is an important reference index in patients with lumbar disease.

III.TEST GROUP

(1) Implementation of the feedback method includes information transmission,patient feedback,clarification and correction,and confirmation of understanding [28].

①Conveying health information

Medical terms were transformed into plain language so that patients could easily understand the health education content.The feedback method was used to explain the pathogenesis of LDH as protrusion or degeneration of the collodium supporting the lumbar spine and rupture of the cartilage protecting the lumbar spine.The protruding collodium compresses the nerve root,leading to pain in the back and leg.

②Patient feedback

After a health message was delivered,the patient was asked to repeat the information back in his own words with the following question:To make sure I’m clear,could you repeat the pathogenesis for me?

③Educator clarification and correction

If the patient had mastered the relevant information,the health education session was ended.If the patient understood some or no information,the steps were repeated,and the educator continued to explain the concept to the patient but changed the way he or she expressed it.

④Checking understanding

Finally,open questions such as the following were used to confirm the patient’s understanding:Do you have any other questions? The patients were then given a chance to sort out the health information.

(2) Patients in the test group received health education according to the feedback method,and the intervention contents and time were as follows:

①One day before surgery:Health education team members provided bedside one-on-one education for patients,15-20 min per session,twice a day.Health education manuals and other tools were used to explain information related to lum-bar intervertebral disc herniation,including the pathogenesis of LDH,clinical manifestations,the significance of relevant examinations,the principle of surgical treatment,and the importance of exercising according to the guidance of doctors,to the patient.The main problem before LDH was pain in the waist and legs,so the patients were advised to take medication and taught how to take neurotropin,mecobalamine,Celebrex and other drugs.

②One week after surgery:One-on-one education on rehabilitation exercise was conducted for the patients by the health education team members,15-20 min per session,twice a day.Day of surgery:The main concerns of the patients were wound pain and axial rolling.After returning to the ward,the patients were taught about pain and the correct use of the analgesic pump.

One week after surgery:The main concerns of the patients were waist circumference and methods of rehabilitation exercise.Patients were instructed to perform straight leg raising exercises,ankle pump exercises and quad contraction exercises,10～20 times/session,3 sessions/day.If the patient understood the relevant knowledge and completed the rehabilitation exercise,the patient was affirmed and encouraged in the form of award certificates,and the "Best Cooperation Award","Best Progress Award","Most Confidence Award","Three Good Fellow Award",etc.,were used to enhance the patient’s self-confidence,sense of honour and sense of achievement in rehabilitation exercise.In terms of discharge guidance,patients were told to go home and continue to perform functional exercise.

③Two to four weeks after surgery:The main concerns of patients were functional exercise and daily life activities.The health education group members guided the patients through functional rehabilitation exercises via WeChat.Each intervention lasted 20-30 min.The patients interacted once through WeChatB1,and their questions were answered at any time.Patients were instructed to perform head lifting training in the prone position,a wood rolling exercise,walking training (waist-assisted) and supine hip flexion and knee flexion exercises,5-10 min/session,3 sessions/day.Patients were required to sign in after receiving new exercises and give feedback.Patients were required to "send a video of themselves performing functional exercise to the group",and the health education team members corrected any incorrect movement or frequency,answered their questions,and confirmed whether they understood until they had fully mastered the correct methods for the functional exercise.WeChat pushed small pieces of information twice via a link.

④Five to 12 weeks after surgery:the main concerns of patients were functional exercise methods,such as five-point support,and other matters needing attention.The health education group members guided patients through the functional rehabilitation exercises via WeChat.Each intervention lasted 20～30 min,and WeChat was used for both sessions.

IV.CONTROL GROUP

The patients underwent routine health education.

V.STATISTICAL ANALYSIS

SPSS 23.0 (IBM Corp.,Armonk,NY,USA) was used for data entry and analysis of the questionnaire,andP<0.05 was considered statistically significant.

VI.CONCLUSION

After learning that LDH patients do not have much knowledge of the disease,we decided to conduct a study on the use of feedback-based health education and functional rehabilitation exercises to address the deficiency of diseaserelated knowledge in these patients.At the same time,understanding of each knowledge point was assessed by having the patient repeat the relevant knowledge of the disease in their own words;if there was a lack of understanding,the patient received more education to strengthen his understanding.Only by providing an appropriate depth and breadth of knowledge can health education provide patients with a good degree of understanding.

Self-efficacy was first proposed by the psychologist Bandura et al.[29].Twelve weeks after the intervention,the General Self-Efficacy Scale score of the experimental group (26.47±2.05)was higher than that of the Yang et al.[30]group for the following reasons:researchers offered health education to patients by using LDH manuals,by providing disease-related knowledge,and by providing feedback on functional exercises.Improving patient self-efficacy can promote rehabilitation from the disease to a certain extent.At the same time,good functional exercises can improve the lumbar function of patients but also promote improvements in self-efficacy,forming a beneficial cycle.

According to the results of this study,both groups of patients had improved medical behaviour after the intervention.The experimental group patients had higher medical behaviour scores than the control group,suggesting that the feedback method of health education and health education in general can improve patients’ medical behaviour,but the effect of the feedback method of health education is better 4 weeks after surgery according to the medical behaviour score (71.05 ±3.75),and these results are consistent with previous work [31].As time goes on,4～12 weeks postoperatively,the patients with LDH had decreased medical behaviour scores.This may have been because the patient experienced pain relief after discharge,and lumbar function had also recovered.Thus,a decline in medical behaviour score in the experimental group,though less than in the control group,shows the ability of the intervention measures to improve and maintain patient health status and that medical behaviour is very important.

Health education based on the feedback method is conducive to improving disease knowledge,general self-efficacy and compliance behaviour and reducing the ODI of patients with lumbar disc herniation;it also improves the muscle strength of these patients.

VII.RELEVANCE TO CLINICAL PRACTICE

This study provides a reference on health education and postoperative rehabilitation in lumbar disc herniation for nurses worldwide.Using feedback theory as the basis,this study applies a feedback method of health education in patients with lumbar disc prolapse,and the intervention content is practical and feasible.This study uses the feedback method to improve the disease-related knowledge and ODI-related indicators of patients with LDH and provides a new direction for future research on LDH patients.

VIII.LIMITATIONS AND STRENGTHS

The intervention time in this study was short,and future studies can extend the intervention time to explore the longterm effect of feedback-based health education on the functional recovery of LDH patients to verify the stability of the results of this study.

IX.DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgements:

Thank all the team members and patients for their cooperation.

This article has been accepted for publication and undergone full peer review but has not been through the copyediting,typesetting,pagination and proofreading process,which may lead to differences between this version and the Version of Record.

This article is protected by copyright.All rights reserved.

Conflict of interest:

The authors have no conflict of interest.

Authors’contributions:

Study design and concept:FanRong,Fan Liang,Gui-Ying Gao,Min Zhang and Gui-Hong Yan;literature search,study selection and data extraction:FanRong;analysis and interpretation of the data:FanRong;drafting and critical revision of the manuscript for important intellectual content:FanRong;All authors commented on the manuscript drafts and read and approved the final manuscript.

Citation:Fan R,Fan LA,Gao GY,Zhang M,Yan GH.Effect of feedback health education on postoperative rehabilitation of patients with lumbar disc herniation:a cluster randomised trials.TMRClinRes.2021;4(3):13.doi:10.53388/TMRCR20210825013

Executive editor:Si-Yu Bian.

Submitted:17 July 2021,Accepted:23 August 2021,

Online:24 August 2021.

© 2021 By Authors.Published by TMR Publishing Group Limited.This is an open access article under the CC-BY license(http://creativecommons.org/licenses/BY/4.0/)