Application of the Enhanced Recovery After Surgery Protocol in Early Intensive Rehabilitation After Laminoplasty: A Mixed Methods Research

doi:10.21203/rs.3.rs-1824381/v1

Background: Perioperative rehabilitation treatment has not been popularized in China, and the team treatment approach still needs to be promoted. In this study, we incorporate early postoperative intensive rehabilitation into the enhanced recovery after surgery (ERAS) protocol of laminoplasty.

Objective: To explore the treatment outcome of postoperative intensive rehabilitation after laminoplasty under the ERAS protocol, by using mixed methods research.

Methods: The intensive rehabilitation group received hospitalized rehabilitation treatment for 1 week while the orthopedic treatment group exercised themselves at home after surgery. Forty-one patients were included in the intensive rehabilitation group and 33 patients in the orthopedic treatment group. The VAS, mJOA, and NDI score of the two groups were compared. Subsequently, through the qualitative research method of a semi-structured interview, 12 patients were selected from each group, and the interview time was 1 week±2 days after surgery. The results of quantitative and qualitative research that represented the same dimensions were compared and integrated for analysis.

Results: Both the quantitative and qualitative research results showed that pain, cervical function, and nerve function of the intensive rehabilitation group were improved at 1 week after surgery. The quantitative research results revealed no significant difference in the VAS, mJOA, and NDI scores between the two groups at 3 months after surgery (P>0.05).

Conclusion: The effect of postoperative intensive rehabilitation treatment was mainly reflected in the improvement of early postoperative function. It could improve pain, cervical function, and nerve function of patients after laminoplasty in the early postoperative period, but there was no significant difference in these parameters in any patients at 3 months after surgery.

Trial registration: NCT, NCT05149404. Retrospectively registered 08/12/2021;

cervical spondylotic myelopathy

laminoplasty

enhanced recovery after surgery

intensive rehabilitation

Cervical spondylosis is a degenerative osteoarthropathy of the cervical spine, and when a patient with cervical spondylosis has the clinical manifestations of spinal cord compression accompanied by sensorimotor disorder, it is known as cervical spondylotic myelopathy(CSM)[1]. For progressive CSM, surgical treatment is needed, and laminoplasty is the first choice for multisegmental CSM[2] . Long-term clinical follow-up results reported satisfactory recovery of the nerve function in patients after surgery[3-5] . However, due to the damage to bony structures, muscles, and soft tissues, complications such as axial symptoms, decreased cervical mobility, and C5 nerve root paralysis often occur after surgery, which slows down the recovery process of patients and affects the overall treatment outcomes.

Enhanced recovery after surgery (ERAS) is a series of perioperative optimization measures based on evidence-based medicine[6]. At the beginning of its establishment, the ERAS concept was mainly based on health economics. When ERAS was introduced in China, “recovery” was translated as “rehabilitation,” giving it the meaning of “rehabilitation,” which has helped rehabilitation medical professionals integrate the concept of functional recovery. According to the characteristics of posterior cervical surgery, researchers in China have published the implementation process of ERAS for posterior cervical surgery[7], further enriching and developing the ERAS concept.

Some researchers proposed that ERAS should aim to reflect patient’s physical condition and feelings, not the doctor’s point of view, which embodying the “patient-centered” treatment principle[8]. Mixed methods research is a research paradigm formed by the organic combination of quantitative and qualitative research methods[9], so it can combine the advantages of the two types of research methods and make up for their limitations[10]. In this paper, mixed methods research is used to evaluate the treatment outcome of intensive rehabilitation under the ERAS protocol.

Design

A convergent design scheme proposed by Creswell et al.[11]is adopted, i.e., quantitative and qualitative research data are collected and analyzed simultaneously, and data representing the same dimension in the results of the two types of research are compared during integration, so as to draw the final research conclusions. The quantitative research part of this study adopts a retrospective cohort study, while the qualitative research is a prospective study. The newly enrolled patients are selected for a semi-structured interview (Fig. 1).

Cohort

This study included patients with cervical spondylotic myelopathy who underwent laminoplasty in Peking University Hospital from January 2018 to November 2019. Patients who accepted early postoperative intensive rehabilitation were included in the intensive rehabilitation group, and others were included in the orthopedic treatment group.

Patients in the intensive rehabilitation group received rehabilitation treatment in hospital for 1 week under the guidance of a professional team composed of rehabilitation doctors, physiotherapists, occupational therapists, and nurses. From the second day after surgery, the training was conducted for approximately 90 minutes each time, twice a day. The nerve function training of the limbs and hands includes proprioceptive neuromuscular facilitation (PNF) practices, muscle strength training and hand function training, up to 40 minutes at a time. Cervical function training includes cervical range of motion training and cervical isometric muscle strength training, up to 20 minutes at a time. Training on transfers, balance and gait up to 30 minutes at a time.

In the orthopedic treatment group, no professional rehabilitation team intervened, and the patients were given routine discharge education and rehabilitation guidance by orthopedic doctors and nurses on the second day after surgery and performed rehabilitation exercises at home according to the guidance content.

Quantitative survey study

Sample

Clinical and follow-up data of patients with CSM (all aged ≥18 years) who underwent laminoplasty in the Department of Orthopedics, Peking University Third Hospital, from January 2018 to January 2019 were retrospectively analyzed. All patients underwent perioperative process management according to the ERAS protocol. Patients with major organic diseases, tumor history, secondary cervical surgery history, and severe osteoporosis were excluded.

Materials

The visual analogue scale (VAS) uses a 10-cm long straight line, of which one end is 0 and the other end is 10, which indicates “painless” and “most painful,” respectively. Patients draw a point on the straight line according to their pain intensity. The modified Japanese Orthopaedic Association (mJOA) score includes upper and lower limb motor and sensory functions, hand function, and sphincter function. It is currently recognized as the evaluation standard of cervical spinal nerve function[12]. The neck disability index (NDI) is a cervical function scale that evaluates the influence of neck pain on the patients’ activities of daily living. It is currently the most widely used evaluation scale for cervical spine function globally, with its reliability and validity effectively verified[13].

In this study, the VAS, mJOA, and NDI scores before surgery and at 3 months (±14 days) after surgery, as well as the scores before (2 days±1 day after surgery) and after (1 week±2 days after surgery) rehabilitation treatment were collected from patients in the intensive rehabilitation group. The VAS, mJOA, and NDI scores before surgery and at 3 months (±14 days) after surgery were collected from patients in the orthopedic treatment group.

Statistical analysis

Research data were processed using SPSS 23.0 software. For description of quantitative indicators, median, 25% quartile, and 75% quartile were calculated, which are expressed as “median (25%, 75% quartile).” Wilcoxon rank-sum test was used for intra-group comparison, and Mann-Whitney rank-sum test was used for inter-group comparison. A P-value < 0.05 was considered to indicate statistically significant differences.

Qualitative interview study

Sample

Patients with CSM (all aged ≥18 years) who underwent laminoplasty in the Department of Orthopedics, Peking University Third Hospital, from May 2019 to November 2019 were selected to participate in the study. All patients underwent perioperative process management according to the ERAS mode. They provided informed consent and signed relevant documents to allow on-site or telephone audio recording during interviews. Patients with major organic diseases, tumor history, secondary cervical surgery history, psychiatric disorders, mental retardation, communication disorders, and severe osteoporosis were excluded.

In the qualitative research, purposive sampling was adopted; patients in the intensive rehabilitation and orthopedic treatment groups were selected and the patients in the two groups corresponded to each other in sex and age. The determination of sample size was based on the principle of information saturation, i.e., contents of the respondents’ interview data were repeated, and data analysis no longer presented new topics[14]. Nvivo 12.0 software was applied to encode and integrate the interview data until no new topics appeared. Finally, 12 patients were included in the intensive rehabilitation group and 12 patients in the orthopedic treatment group.

Methods

In this study, the convergent design was adopted in the mixed methods research, so questions in the interview outline of qualitative research were generated, with a focus on the dimensions involved in quantitative observation indicators, namely, postoperative pain, cervical function, and nerve function. Patients were asked about changes in their postoperative symptoms, medical care experiences and feelings, and evaluation of the treatment effect. All questions were open, and the interview outline is shown in Tab. 1.

Tab. 1 Outline of the qualitative interview

Intensive rehabilitation group

Orthopedic treatment group

1. Why did you undergo the operation?

2. What improvements have you made in the rehabilitation department this week?

3. What symptoms remain?

4. What difficulties do you experience during postoperative rehabilitation?

5. How do you feel during the rehabilitation process?

6. How do you evaluate the rehabilitation effect in the rehabilitation department?

1. Why did you undergo the operation?

2. What rehabilitation exercises and treatments do you perform at home?

3. How is your disease recovering?

4. What symptoms remain?

5. What difficulties did you experience in the week after you came home?

6. How are you feeling at home this week?

7. What other help do you need from me?

Patients in the intensive rehabilitation group were interviewed face-to-face after 1 week of rehabilitation treatment (1 week±2 days after surgery), and those in the orthopedic treatment group were interviewed through telephone in the same time period after surgery. Semi-structured, in-depth interview was conducted for both groups. Before the interview, the researcher inquired about patients willingness to be interviewed, and asked them to sign the informed consent form[15]. In this study, all 24 patients successfully completed the interview, and the audio recording materials of the interview were retained. Within 24 hours after each interview, the researcher would personally check the recorded content, and after the privacy information was concealed, the recorded content was transcribed into a verbatim transcript using a third-party platform. After the transcription was completed, the researcher would personally correct and check the transcript and keep the data properly.

Statistical analysis

The qualitative research data were processed using Nvivo 12.0 software, and the transcription materials were coded and integrated to form topics. The analysis method employed was the thematic content analysis method recommended by Hsieh et al.[16] First, the researcher read the materials repeatedly and fully obtained the information in the data. Then, the researcher marked the important contents and concepts in the materials and encoded them in an open way. Finally, similar or related codes were classified to form the topic, and the researcher defined the topic and found corresponding excerpts from the materials to interpret the contents of the topic.

Mixed methods integration and analysis

In this study, data representing the same dimension in the quantitative and qualitative results were compared and analyzed so as to obtain the integrated results of the data on each dimension. The principle of integrated analysis is as follows: if the results of two types of data confirm each other, they will be recorded as “confirmation;” if the results of two types of data complement each other, they will be recorded as “expansion;” and if the results of two types of data contradict each other, they will be recorded as “discordance”[17].

Quantitative survey study

Comparison of basic information

A total of 74 patients were included in the quantitative research, including 41 patients in the intensive rehabilitation group and 33 in the orthopedic treatment group. The medical records and follow-up data of the VAS, mJOA, and NDI scores of all patients before surgery and at 3 months after surgery were complete. In the intensive rehabilitation group, 34 (82.9%) patients had complete medical records of the VAS, mJOA, and NDI scores before and after 1 week of rehabilitation treatment.

In the basic information, there was no statistically significant difference in age, sex, BMI, operative segment, postoperative C5 nerve root paralysis rate, or the preoperative VAS and NDI scores between the intensive rehabilitation and orthopedic treatment groups (P>0.05). However, there was statistically significant difference in the mJOA score (P<0.05), which was higher in the intensive rehabilitation group than in the orthopedic treatment group (see Tab. 2).

Tab. 2 Comparison of basic information of patients

Item	Intensive rehabilitation group (n=41)	Orthopedic treatment group (n=33)	P
Age (years)	57.1±9.3	58.6±10.4	0.314
Sex
Male	31	25	0.988
Female	10	8
BMI (kg/m²)	25.6±2.8	25.9±3.1	0.287
Surgical segment
C3-7*	24	17	0.546
Non-C3-7**	17	16
C5 nerve root paralysis
No	36	29	0.992
Yes	5	4
VAS	2 (0, 4)	3 (0, 5)	0.746
mJOA	14.0 (12.5, 14.5)	12.0 (11.0, 13.5)	0.003***
NDI	8 (0, 15)	7 (0, 17)	0.960

* Posterior cervical expansive laminoplasty for C3-7 segments

** Posterior cervical expansive laminoplasty for non-C3-7 segments

*** There was statistically significant difference between the two groups.

Influence of preoperative nerve function on results

In this study, the preoperative mJOA score difference between the two groups was statistically significant (P < 0.05) (see Tab. 2). The preoperative nerve function score of the intensive rehabilitation group was higher than that of the orthopedic treatment group. Therefore, it is necessary to first explore whether the baseline difference in nerve function has a significant impact on postoperative efficacy.

In previous studies, nerve function improvement rate was calculated by mJOA score to judge postoperative efficacy, and improvement rate ≥25% was considered effective[18].Improvement rate = (postoperative mJOA score - preoperative mJOA score)/(17- preoperative mJOA score) ×100%. As shown in Table. 3, there was no significant difference in nerve function improvement rate 3 months after surgery between the two groups (P > 0.05), indicating that the difference in preoperative mJOA score had no significant effect on postoperative efficacy.

Tab. 3 Comparison of nerve function improvement rate between the two groups 3 months after surgery

Item	Intensive rehabilitation group (n=41)	Orthopedic treatment group (n=33)	P
Improvement rate			0.628
≥25%	29	25
＜25%	12	8

Comparison of observation indicators between the two groups at 3 months after surgery

There was no statistically significant difference in the VAS, mJOA, or NDI score between the intensive rehabilitation and orthopedic treatment groups at 3 months after surgery (P>0.05) (see Tab. 4).

Tab. 4 Comparison of observation indicators between the two groups at 3 months after surgery

	Intensive rehabilitation group (n=41)	Orthopedic treatment group (n=33)	P
VAS	3(1, 5)	3 (1, 5)	0.549
mJOA	16.0 (14.0, 16.5)	15.5 (13.5, 16.5)	0.813
NDI	7 (3, 12)	10 (4, 14)	0.401

Comparison before and after 1 week of rehabilitation treatment in the intensive rehabilitation group

The VAS, mJOA, and NDI scores in the intensive rehabilitation group before (at 2 days after surgery) and after (at 1 week after surgery) rehabilitation treatment were significantly different (P<0.05) (see Tab. 5), and the above scores were improved after rehabilitation treatment compared with before rehabilitation treatment.

Tab. 5 Comparison before and after rehabilitation treatment for 1 week in the intensive rehabilitation group

	Before rehabilitation (at 2 days after surgery)	After rehabilitation (at 1 week after surgery)	P
VAS	4 (3, 6)	3 (2, 4)	0.001
mJOA	14.0 (13.0, 15.5)	15.5 (14.5, 16.0)	<0.001
NDI	18 (13, 23)	12 (6, 17)	<0.001

Qualitative interview study

All patients successfully completed the interview, and audio recording materials of the interview were retained. The age of the 24 patients ranged from 39 to 77 years. There were 10 male patients and 2 female patients in each study group. The disease course was less than 1 year in 7 patients, 1–10 years in 10 patients, and more than 10 years in 7 patients. The researcher summarized the interview contents into the following topics, each of which had its corresponding subtopics (see Tab. 6).

Tab. 6 Topics and subtopics

Topics	Subtopics
Effectiveness of intensive rehabilitation treatment	Pain management is timely and effective The mobility of the cervical spine has been increasing day by day The nerve function of limbs has been improved The quality of daily life has been improved Timely communication and feedback between doctors and patients
Limitations of intensive rehabilitation treatment	Legacy nerve dysfunction New-onset neuropathic pain
Changes in behavior and awareness by intensive rehabilitation treatment	Dare to perform activities early after rehabilitation Psychological improvement effect of rehabilitation

Mixed methods integration and joint display

The quantitative and qualitative research results were compared and analyzed according to the three dimensions of postoperative pain, cervical function, and nerve function, and the following integrated results were obtained (see Tab. 7):

(1) The results of quantitative and qualitative research revealed that the pain, cervical function, and nerve function in the intensive rehabilitation group were improved at 1 week after surgery.

(2) The results of quantitative research revealed no significant difference in the VAS, mJOA, or NDI scores between the two groups at 3 months after surgery (P>0.05).

(3) The results of qualitative research revealed that the improvement in pain, cervical function, and nerve function in the orthopedic treatment group was smaller than that in the intensive rehabilitation group at 1 week after surgery.

Tab. 7 Integration of quantitative and qualitative research data

Dimension

Quantitative research data

Qualitative research interview content

Integrated results

Postoperative pain

1. There was no statistically significant difference in the VAS score between the two groups at 3 months after surgery (P>0.05).

2. There was statistically significant difference in the VAS score before and after 1 week of rehabilitation treatment in the intensive rehabilitation group (P<0.05).

Pain management is timely and effective

“At that time (when the pain was severe), I could say it was extremely painful ... I told the doctor, and he treated me ... very timely, fully and with great effect.”

(Patient 19, intensive rehabilitation group)

“I take analgesics in my house now because it hurts so much ... (after taking the medicine in my house) it’s only a little better. It still affects me (daily life) and it hurts even more when I sit down or lie down.”

(Patient 1, orthopedic treatment group)

(1) In the intensive rehabilitation group, pain improved at 1 week after surgery. (Conformation)

(2) Pain improvement in the orthopedic treatment group was smaller than that in the intensive rehabilitation group at 1 week after surgery (Expansion, qualitative research).

(3) At 3 months after surgery, there was no significant difference in the VAS score between the two groups. (Expansion, quantitative research)

Cervical vertebra function

1. There was no statistically significant difference in the NDI score between the two groups at 3 months after surgery (P>0.05).

2.There was statistically significant difference in the NDI score before and after 1 week of rehabilitation treatment in the intensive rehabilitation group (P<0.05).

The mobility of the cervical spine has been increasing day by day

“(Cervical activity training) is slowly step by step. I feel that anyway, I can do greater amplitude day by day ... After all, this is professional, so we are not good at mastering the amplitude of the action. The therapist taught me some movements to do at home. He said that he wanted me to do a resistance movement with him. When he led me to do the movement, it didn’t hurt at all. When I tried hard myself, I felt the pain.”

(Patient 13, intensive rehabilitation group)

“When I practice at home, I always sit there, but I dare not exert myself very hard. I am afraid that the way I move or something may be wrong ... I can only see the bowl in front of me when I eat now. The dishes should be brought to me when I want to fetch them, and I have to lift my bowl when I fetch the dishes.”

(Patient 5, orthopedic treatment group)

(1) In the intensive rehabilitation group, cervical function improved at 1 week after surgery. (Conformation)

(2) The improvement of cervical function in the orthopedic treatment group was smaller than that in the intensive rehabilitation group at 1 week after surgery. (Expansion, qualitative research)

(3) At 3 months after surgery, there was no significant difference in the NDI score between the two groups. (Expansion, quantitative research)

Nerve function

1. There was no statistically significant difference in the mJOA score between the two groups at 3 months after surgery (P>0.05).

2. There was statistically significant difference in the mJOA score before and after 1 week of rehabilitation in the intensive rehabilitation group (P<0.05).

The nerve function of limbs has been improved

“This surgery was performed, which enlarged the space (cervical spinal canal). My hands and feet, which were previously numb, became conscious as soon as the surgery was completed ... These seven days must be effective. I did treadmill every day, picked up balls and lifted boxes in front of a computer machine, which all exercised my grip strength, and this hand has been recovering.”

(Patient 23, intensive rehabilitation group)

“After returning home, I feel that the strength of my legs hasn’t changed much, and I still have some floating and unreal feeling when I walk.

(Patient 3, orthopedic treatment group)

(1) In the intensive rehabilitation group, the nerve function improved at 1 week after surgery. (Conformation)

(2) The improvement of nerve function in the orthopedic treatment group was smaller than that in the intensive rehabilitation group at 1 week after surgery. (Expansion, qualitative research)

(3) At 3 months after surgery, there was no significant difference in the mJOA score between the two groups. (Expansion, quantitative research)

In developed countries in Europe and America, a team approach is adopted for the treatment of orthopedic diseases, in which orthopedics, rehabilitation physicians, rehabilitation therapists, and nurses form a treatment group and orthopedic surgical treatment and functional recovery are organically combined to help patients recover and return to society better, faster, more comprehensively, and more effectively[19]. However, in the existing conventional orthopedic treatment mode in China, perioperative rehabilitation treatment has not been popularized, and the team treatment approach still needs to be promoted. In this study, the concept of perioperative rehabilitation was introduced into ERAS. For patients who had undergone laminoplasty, intensive rehabilitation treatment by a professional rehabilitation team was performed in the early postoperative period, and the influence of intensive rehabilitation treatment on the postoperative functions of patients was investigated. Using mixed methods research, quantitative and qualitative data on postoperative functions were collected simultaneously; finally, data from the two types of research were compared and integrated to explore the treatment outcomes of intensive rehabilitation after laminoplasty under the ERAS protocol.

Effect of intensive rehabilitation treatment on postoperative pain

In this study, we proved the improvement effect of intensive rehabilitation treatment on early postoperative pain. Beloeil et al.[20] believed that the more severe the postoperative pain, the greater the probability of developing chronic pain and the longer the duration. Posterior cervical surgery is associated with a relatively large incision and relatively serious soft tissue injury; therefore, postoperative pain management is very important for early postoperative rehabilitation. In this study, there was no significant difference in the VAS score between the intensive rehabilitation and orthopedic treatment groups at 3 months after surgery, which was related to the follow-up time of this study. In the follow-up of patients undergoing cervical expansive laminoplasty with the unilateral musculo-ligamentous complex preserved, Yu et al.[21] found that the rate of hinge union reached 79.1% at 3 months after surgery. Therefore, at this time point, the muscles, soft tissues, and bone structures have basically recovered and healed, resulting in no significant difference in postoperative pain between the two groups.

The results of the qualitative interviews showed that the effect of intensive rehabilitation treatment was not promising for patients with postoperative new-onset neuropathic pain. The typical manifestation of neuropathic pain after cervical spine surgery is acupuncture-like, electric shock-like, or knife cutting-like pain, which is usually distributed in non-axial areas[22]. Fletcher et al.[23] found that approximately 30% of severe postoperative chronic pain cases include cases of neuropathic pain, which seriously affects the quality of life of patients after surgery. In this study, patients in the intensive rehabilitation group suspected of having postoperative neuropathic pain were all screened using the DN4 questionnaire in the hospital[20], and the confirmed patients were provided corresponding treatment. However, neuropathic pain has complex and diverse clinical manifestations, making it a refractory pain. Therefore, it is often difficult for patients with postoperative new-onset neuropathic pain to obtain satisfactory treatment outcomes during short-term intensive rehabilitation treatment.

Effect of intensive rehabilitation treatment on cervical spine function

In this study, both quantitative and qualitative studies have confirmed that intensive rehabilitation treatment could improve the cervical function of patients in the early postoperative period. Patients were guided by the professional rehabilitation personnel, so as to restore and increase the range of joint motion. In a 5-year follow-up study, Hyun et al.[24] found that cervical range of motion(CROM) decreased by 38.5% on average within 5 years after surgery, and this decrease was time-dependent, i.e., the initial ROM gradually decreased and part of the ROM could be recovered within 5 years. Takeuchi et al.[25] preserved the semispinalis cervicis attached to C2 during surgery and found that CROM decreased by 19% between 1 and 2 years after surgery. Through qualitative research, this study found that early intensive rehabilitation could improve CROM, however, corresponding quantitative data to support this are limited, so further research is still needed.

Effect of intensive rehabilitation treatment on nerve function

At present, it is internationally recognized that the treatment of CSM should mainly be surgical treatment, and Rhee et al.[26] believed that the treatment outcomes of non-surgical treatment have not been effectively verified clinically. Multicenter prospective research conducted in North America by AO Spine showed that cervical spinal cord decompression could prevent deterioration of the disease as well as improve the neurological outcomes and functional status of patients regardless of the severity of disease[27]. In this study, at 3 months after surgery, the mJOA scores has no significant difference between the two groups. These study results showed the effectiveness of surgical treatment under the ERAS protocol and demonstrated that short-term intensive rehabilitation treatment could not significantly improve the nerve function outcomes of patients. Because age, duration of symptoms, and preoperative nerve function are important prognostic indicators for CSM[28]. However, in this study, after intensive rehabilitation treatment for 1 week, the mJOA scores of patients in the intensive rehabilitation group were significantly different from those before treatment; the qualitative interview results also confirmed that intensive rehabilitation treatment could improve the nerve function of limbs, so this study confirmed the effect of intensive rehabilitation treatment in improving nerve function in the early postoperative period.

The application of the ERAS protocol in intensive rehabilitation after laminoplasty could improve early postoperative function as well as pain, cervical function, and nerve function of patients in the early postoperative period after laminoplasty. There was no significant difference in pain, cervical function, or nerve function at 3 months after surgery.

ERAS: Enhanced recovery after surgery; VAS: Visual analogue scale; mJOA: Modified Japanese Orthopaedic Association; NDI: Neck disability index; CSM: Cervical spondylotic myelopathy; PNF: Proprioceptive neuromuscular facilitation.

Acknowledgments

The authors acknowledge the team of physical therapists responsible for the treatment of participants. The authors also thank all the participants who have taken part in this research and for sharing their feelings.

Author Contributions

Concept and design: Zhang, Chu. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript:.Zhang. Critical revision of the manuscript for important intellectual content: Mouwang Zhou, Feifei Zhou. Statistical analysis: Zhang, Chu. Obtained funding: Liu, Feifei Zhou. Supervision: Mouwang Zhou. Final approval of the version to be published: all.

Funding

This study was funded by Young Elite Scientists Sponsorship Program By Cast(YESS20180055 to Xiaoxie Liu) , Youth Program Fund of Clinical Key Program of Peking University Third Hospital(BYSY2017028 to Feifei Zhou) and Capital Health Research and Development of Special Fund (SF2020-1-4092 to Yu Sun).

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Research Ethics Committee of Peking University Third Hospital(No. M2019144) (Beijing, China) in accordance with the Declaration of Helsinki. All patients who participated in this study voluntarily signed the informed consent before discharge from the hospital. The patients were informed that they could refuse to answer any questions and withdraw from the study at any time.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

¹Department of Rehabilitation Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, China. ³Department of Orthopaedic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, China.

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No competing interests reported.

Application of the Enhanced Recovery After Surgery Protocol in Early Intensive Rehabilitation After Laminoplasty: A Mixed Methods Research

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Abstract

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Background

Methods

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Discussion

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