Understanding the Patient Perspective When Designing Future Rehabilitation Interventions after Hip or Knee Replacement Surgery-A Patient and Public Involvement Exercise.

Background and Objectives: Following discharge from hospital, there can be variability in the rehabilitation of patients who have undergone total hip or knee replacement surgery. We invited patients who had had hip or knee replacement surgery to take part in patient and public involvement sessions to help us understand their recovery needs and how rehabilitation services could potentially be improved to meet these needs better. Materials: Patients (n = 14) were invited to one of two patient advisory group sessions which took place in a university setting. Results: Feedback from patients highlighted the need for an inclusive, evidence-based intervention that would benefit patients experiencing all levels of pain, with differing motivations for recovery. Patients desired social support with others who have had similar surgery to reduce the burden of isolation during rehabilitation. Furthermore, patients valued the involvement of their partners and carers in their rehabilitation, to provide social support and guidance on recovery. Patients also expressed a need for consistent information and expert guidance on all aspects of their recovery. Conclusions: These findings can be used to guide the design of rehabilitation interventions following hip and knee replacement and ensure that patient perspectives inform future practice.

What Is Important to the Younger Person (≤50 Years) When Having a Total Hip Arthroplasty: A Systematic Literature Review.

Total hip arthroplasties (THAs) are usually performed in older patients. Despite a growing number of THAs in younger adults, it is unclear whether they have similar priorities in recovery compared with their older counterparts. The purpose of this systematic review was to explore younger patients' priorities when undergoing a THA. Multiple databases were searched in September 2021 prioritizing qualitative data. This review was reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Of 14,495 articles screened, nine remained for analysis. Four common themes were discovered: improving function and mobility; pain; relationships; and patient expectations and education. However, there was insufficient information to clarify whether these themes could be attributed directly to younger adults undergoing a THA. The absence of research on THA patients younger than 50 years results in the loss of the voices of these patients. Further research is essential to ensure their needs are identified, addressed, and met.

A 1RM Strengthening and Exercise Programme for the Treatment of Knee Osteoarthritis: A Quality-Improvement Study.

Background: The Kneefit programme is a 12-week strengthening and exercise programme, personalised using body-weight ratios, for people with knee osteoarthritis. Objectives and Design: This quality-improvement study was conducted to evaluate the effectiveness of the programme for managing symptomatic knee osteoarthritis. Methods: The Kneefit programme was delivered between 20 August 2013 and 7 January 2014 and included six weeks of supervised strengthening, balance, and cardiovascular exercise in a group at the local hospital, followed by six weeks of unsupervised exercise. Leg-press and knee-extension 1RM scores were assessed at baseline, six weeks, and twelve weeks. In addition, patient-reported outcome measures (Oxford Knee Score, EQ5D, Patient Specific Function Score (PSFS)) were assessed. Wilcoxon Signed Rank tests were used to evaluate the changes from week 1 to week 6 and week 12. Results: Thirty-six patients were included at baseline and at six weeks, and 31 patients completed their twelve-week assessment. Statistically significant improvements were found at 6 and 12 weeks for change for the Oxford Knee Score (median change: 4.0, IQR 4.0 to 9.0, p < 0.001 and 4.0, IQR 0 to 8.0, p < 0.001), EQ5D-5L (median change: 0.078, IQR 0.03 to 0.20, p < 0.001 and 0.071, IQR 0.02 to 0.25, p < 0.001) and the PSFS (median change: 1.3 IQR 0 to 2.6, p = 0.005 and 2.3 IQR -0.3 to 3.3, p = 0.016). In addition, significant improvements were found for 1RM leg-press and knee-extension scores on both the affected and unaffected legs. Conclusion: The Kneefit programme was successful at improving both functional and strength-related outcome measures in patients with knee osteoarthritis. Our findings suggest that tailoring strength exercises based on the 1RM strength-training principles is feasible in this population.

CycLing and EducATion (CLEAT): protocol for a single centre randomised controlled trial of a cycling and education intervention versus standard physiotherapy care for the treatment of hip osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic degenerative joint disorder for which there is no known cure. Non-surgical management for people with mild-to-moderate hip OA focuses mainly on alleviating pain and maximising function via the National Institute for Health and Care Excellence (NICE) recommended combination of education and advice, exercise, and, where appropriate, weight loss. The CHAIN (Cycling against Hip pAIN) intervention is a group cycling and education intervention conceived as a way of implementing the NICE guidance. METHODS: CycLing and EducATion (CLEAT) is a pragmatic, two parallel arm, randomised controlled trial comparing CHAIN with standard physiotherapy care for the treatment of mild-to-moderate hip OA. We will recruit 256 participants referred to the local NHS physiotherapy department over a 24-month recruitment period. Participants diagnosed with hip OA according to NICE guidance and meeting the criteria for GP exercise referral will be eligible to participate. Primary outcome is the difference in Hip Disability and Osteoarthritis Outcome Score (HOOS) function, daily living subscale between those receiving CHAIN and standard physiotherapy care. Secondary outcomes include performance-based functional measures (40 m walking, 30s chair stand and stair climb tests), ability for patient to self-care (patient activation measure) and self-reported health-related resource use including primary and secondary care contacts. The primary economic endpoint is the number of quality adjusted life years (QALYs) at 24 weeks follow-up. The study is funded by the National Institute for Health Research, Research for Patient Benefit PB-PG-0816-20033. DISCUSSION: The literature identifies a lack of high-quality trials which inform on the content and design of education and exercise in the treatment of patients with hip OA and explore cost-effectiveness. CLEAT is a pragmatic trial which seeks to build further evidence of the clinical benefits of the CHAIN intervention compared to standard physiotherapy care within a randomised, controlled trial setting, and examine its cost-effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN19778222. Protocol v4.1, 24th October 2022.

Volumetric assessment of lower limb oedema using 3D laser scanning technique: a systematic review.

Clinically, oedema is described as an abnormal build-up of interstitial fluid in the body that is enough to produce palpable swelling. Its assessment offers valuable information to clinicians as this can inform management interventions; and help monitor adherence to home therapy programmes and activity levels. The aim of this systematic review is to establish the utility of 3D scanning technologies in the assessment of lower limb oedema. A computer-based search was completed in October 2020. Four studies were identified which utilised a 3D scanner to measure lower limb oedema. A review of the studies found very little evidence to support the efficacy of 3D laser scanning technology, although they show that the use of the technology is feasible. Current methods of lower leg oedema measurement have issues with reliability, practicability and time taken. There is a need for future studies to validate new methods of oedema assessment using technologies such as 3D laser scanning.

A cycling and education intervention for the treatment of hip osteoarthritis: A quality improvement replication programme.

OBJECTIVES: The Cycling against Hip Pain programme is a 6-week exercise and education treatment pathway for people with hip osteoarthritis. Preliminary results of the Cycling against Hip Pain programme found significant improvements in clinical and patient-reported outcome measures for patients referred from primary care. This article evaluates the effectiveness of the changes made to the pathway in a quality improvement replication programme. METHODS: The replicated Cycling against Hip Pain programme was delivered between February 2018 and September 2019 in a region of England with a high percentage of adults aged over 65 years. All participants were referred from the orthopaedic outpatient department of the funding hospital (secondary care). The programme was delivered at a local leisure centre and combined 30 min of education on osteoarthritis with 30 min of progressive static cycling, once a week for 6 weeks. RESULTS: The participants on the replicated Cycling against Hip Pain programme did not differ from the original cohort in terms of age or pre-programme weight, however, presented with worse hip symptoms at baseline. Consistent with the findings from the original cohort, participants demonstrated significant improvements to their Oxford Hip Score, 30-s chair stand performance, Timed Up and Go score, Hip Osteoarthritis Outcome Score function and pain, EQ5D health rating, EQ5D-5L score and pain at rest and on weight bearing. In addition, participants reported an increase in knowledge, confidence and motivation to exercise. CONCLUSION: A 6-week cycling and education intervention for the treatment of hip osteoarthritis provided benefits to function, pain and quality of life for patients referred from secondary care. These results are consistent with findings from patients who were referred from primary care and further support the potential of the pathway in the conservative management of hip osteoarthritis.

Self-Management of Hip Osteoarthritis Five Years After a Cycling and Education Treatment Pathway.

The Cycling against Hip Pain (CHAIN) programme is a six-week cycling and education treatment pathway for people with hip osteoarthritis. Preliminary results demonstrated significant improvements in clinical and patient-reported outcome measures following the course. Whilst the benefits of exercise for osteoarthritis are often reported in the short term, less is known about the long-term effects for this patient group. This study explores whether participants continued to self-manage their hip osteoarthritis five years after completing the course. A cross-sectional survey was conducted to collect data from participants who completed the CHAIN programme between October 2013 and February 2015 (n = 96). Questionnaires were sent by post in April 2019, and then non-responders were followed up again four weeks later. Eighty-three (87%) participants responded to the survey. Five years (range 4-6) after completion of a six-week cycling and education programme, 37 (45%) participants had not returned to their general practitioner for further treatment of their hip pain, and 47 (57%) had not pursued surgical intervention. All participants were still engaged in at least one physical activity per week and many reported that they had purchased a bike (29%), joined a gym (30%) or cycled regularly (indoor cycling 25%, outdoor cycling 24%). Eighty (96%) participants reported an increase in knowledge of self-managing their symptoms. The findings from this study suggest that many patients are motivated to self-manage their hip osteoarthritis, five years following a six-week cycling and education treatment pathway that encourages lifestyle change.

Enhanced Recovery After Surgery: Concepts and Application to Total Shoulder Replacement.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement. PURPOSE: To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery. METHODS: Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken. RESULTS: Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management. CONCLUSIONS: Future research is now required for ERAS procedure-specific components for TSR surgery.

Validation of the Anterior Cruciate Ligament (ACL) Module of the VirtaMed Virtual Reality Arthroscopy Trainer.

OBJECTIVE: To assess the newly developed anterior cruciate ligament (ACL) module of a VR arthroscopy trainer for content, construct and face validity. DESIGN: Participants were divided into expert and novice groups based on their experience with ACL arthroscopy. Participants were given a standardized introduction, shown a video on how to use the simulator, and performed a 5-minute partial meniscectomy task, to familiarise them with the equipment. Participants then undertook an ACL reconstruction task. On completion, the simulator produced a summary of performance metrics for the following domains: Operation Time, ACL Reconstruction, Safety, Economy, Detailed Visualization and Total Score. A 7-point Likert scale questionnaire was used to assess the face and content validity of the simulator. PARTICIPANTS: Twenty one participants from a hospital orthopaedic department were recruited. Five were classified as expert, 16 as novice. RESULTS: An independent Mann-Whitney U test showed no significant differences between experts and novices for any of the domains. Questionnaire responses regarding hand-eye coordination, camera navigation training, diagnostic training, tunnel preparation and overall training capacity were scored as either 'good' or 'excellent' by more than 70% of the participants. All responses regarding the 'graft insertion task' scored low. CONCLUSION: The current iteration of the VR knee ArthroS™ simulator (VirtaMed AG, Zurich, Switzerland) is promising, but requires further development of the ACL procedure, in particular the graft insertion task, before it can be considered as part of training curricula.

Validation of joint angle measurements: comparison of a novel low-cost marker-less system with an industry standard marker-based system.

Human motion tracking is widely used for the assessment of movement dysfunction in orthopaedic patients. Currently, most clinical motion analysis centres use marker-based three-dimensional (3D) systems as they are deemed to be the most accurate method. However, due to space, costs and logistics they are not available in many clinical settings. This study compared joint angles measured in functional tests using the novel low-cost Microsoft Kinect Perfect Phorm system with the established marker-based Nexus VICON system. When measuring right and left knee flexion, the average difference between the VICON and Kinect Perfect Phorm measurement was 13.2%, with a SD of 19.6. Both overestimation and underestimation of the joint angle was recorded in different participants. Although the average percentage difference during hip abduction tests was lower at -3.9%, the range of error was far greater (SD = 75). From this, it can be concluded that the level of accuracy presented in the new low-cost Kinect Perfect Phorm system is not yet suitable for clinical assessments. However, for general tests of performance, and for tracking cases where absolute accuracy is less critical, future versions of this software may have a place.

Effectiveness of neuromuscular electrical stimulation for reducing oedema: A systematic review.

OBJECTIVE: This systematic review aimed to assess the clinical impact of neuromuscular electrical stimulation as a treatment modality for patients with oedema. DATA SOURCES AND STUDY SELECTION: PubMed was searched up to July 2018 for randomized and non-randomized clinical trials comparing neuromuscular electrical stimulation vs no stimulation following the formation of oedema. A modified Downs and Black checklist was used to evaluate the quality of the evidence. DATA SYNTHESIS: Initial searches yielded 150 results. Removal of duplicates reduced this number to 97 results. Seventy-five studies were excluded following a review of titles and abstracts. Full-text screening eliminated 15 studies. A final total of 7 studies met the inclusion criteria. Six studies supported the use of neuromuscular electrical stimulation for oedema reduction, and one study did not find an effect, but reported inter-group variance. CONCLUSION: The results of this systematic review support the use of neuromuscular electrical stimulation for ameliorating the abnormal accumulation of interstitial fluid, which is clinically shown as oedema. Neuromuscular electrical stimulation is effective in a number of rehabilitation settings and patient groups, for treatment of both upper and lower limb oedema. However, further trials are needed to reinforce these findings.

Does aquatic exercise improve commonly reported predisposing risk factors to falls within the elderly? A systematic review.

BACKGROUND: According to the World Health Organization, the elderly are at the highest risk of injury or death from a fall. Age-related changes in strength, balance and flexibility are degenerative factors that may increase the risk of falling, and an aquatic training may offer a favourable environment to improve these modifiable risk factors. METHODS: A systematic review was conducted to assess the potential preventative role of aquatic exercise for reducing the risk of falls in the elderly by improving predisposing risk factors. Electronic databases and reference lists of pertinent articles published between 2005 and 2018 were searched. Randomized controlled trials (RCTs) that directly or indirectly addressed the effect of aquatic exercise for the prevention of falls in healthy participants were included within the synthesis. Studies were included if they were reported between January 2005 and May 2018 within a population aged between 60 and 90 years old that were without exercise-effecting comorbidities. Data related to participant demographics, study design, methodology, interventions and outcomes was extracted by one reviewer. Methodological quality assessment was independently performed by two reviewers using the PEDro (Physiotherapy Evidence Database) scale. RESULTS: Fourteen trials met the inclusion criteria. Exercise intervention duration and frequency varied from 2 to 24 weeks, from 2 to 3 times per week, from 40 to 90 min per session. Fall rate was not reported in any of the studies analysed. However, aquatic exercise improved key predisposing physical fitness components that are modifiable and internal risk factors for falling. CONCLUSIONS: There is limited, low-quality evidence to support the use of aquatic exercise for improving physiological components that are risk factors for falling. Although the evidence is limited, and many interventions are not well described, these results should be considered by health and exercise professionals when making evidence-based, clinical decisions regarding training programmes to reduce the risk of falling.

Validation of the Hip Arthroscopy Module of the VirtaMed Virtual Reality Arthroscopy Trainer.

OBJECTIVE: To assess the face, content and construct validity of a virtual reality hip arthroscopy simulator (Arthros™, VirtaMed AG, Schlieren, Switzerland). DESIGN: Participants were divided into Expert and Novice groups depending on whether or not they had assisted with or performed more than 50 hip arthroscopy procedures. Participants were given a standardized introduction and shown a video on how to use the simulator. To familiarise themselves with the equipment, they were then given a 5-minute diagnostic task to complete. Participants then performed a therapeutic task. On completion, the simulator produced a summary of performance metrics for the following domains: Operation Time, Safety, Economy, Detailed Visualization and Overall Score. Participants completed a 7-point Likert-scale questionnaire to assess the face and content validity of the simulator. SETTING: University lab or exhibition stand at an orthopaedic conference. PARTICIPANTS: Clinicians from a hospital orthopaedic department and attendees at a UK orthopaedic conference with varying levels of experience in hip arthroscopy surgery. RESULTS: Twenty-two participants were recruited. Six were classified as Expert and 16 as Novice. Statistically significant differences were found between the Expert and Novice groups for Overall Score (p=0.001), Safety (p=0.002) and Economy (p=0.033), but not Detailed Visualization (p=0.097). Questionnaire responses were positive for all items related to face and content validity. CONCLUSION: This study suggests that training on the ArthroS™ VR hip arthroscopy simulator has construct, face and content validity. It expands the evidence base for VR simulator training and is the first study to evaluate this hip arthroscopy module.

Can the introduction of Enhanced Recovery After Surgery (ERAS) reduce the variation in length of stay after total ankle replacement surgery?

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has been successfully adopted across a range of procedures. This study explores whether there is scope to improve length of stay (LOS) for total ankle replacement surgery (TAR) in the UK by implementing ERAS pathways. METHODS: Hospital Episode Statistics (HES) data (April 2015/March 2016) on LOS for TAR were analysed. A literature search was then carried out to examine whether there were any publications on outpatient TAR and/or the use of ERAS protocols. RESULTS: Mean observed LOS was 3.3days (range 0-17.3) days. Case mix-adjusted expected LOS range was 2.0-5.7 days. It is likely that the wide observed LOS range is due to differences in local processes and pathways. Two papers were found by the literature search. CONCLUSIONS: TAR should aim to be outpatient surgery as the literature, and data demonstrating scope for improvement in LOS, suggest this should be possible.

A review of wearable motion tracking systems used in rehabilitation following hip and knee replacement.

Clinical teams are under increasing pressure to facilitate early hospital discharge for total hip replacement and total knee replacement patients following surgery. A wide variety of wearable devices are being marketed to assist with rehabilitation following surgery. A review of wearable devices was undertaken to assess the evidence supporting their efficacy in assisting rehabilitation following total hip replacement and total knee replacement. A search was conducted using the electronic databases including Medline, CINAHL, Cochrane, PsycARTICLES, and PubMed of studies from January 2000 to October 2017. Five studies met the eligibility criteria, and all used an accelerometer and a gyroscope for their technology. A review of the studies found very little evidence to support the efficacy of the technology, although they show that the use of the technology is feasible. Future work should establish which wearable technology is most valuable to patients, which ones improve patient outcomes, and the most economical model for deploying the technology.

A Novel Approach to Overcome Movement Artifact When Using a Laser Speckle Contrast Imaging System for Alternating Speeds of Blood Microcirculation.

The laser speckle contrast imager (LSCI) provides a powerful yet simple technique for measuring microcirculatory blood flow. Ideal for blood dynamic responses, the LSCI is used in the same way as a conventional Laser Doppler Imager (LDI). However, with a maximum skin depth of approximately 1 mm, the LSCI is designed to focus on mainly superficial blood flow. It is used to measure skin surface areas of up to 15 cm x 20 cm. The new technique introduced in this paper accounts for alternating speeds of microcirculations; i.e. both slow and fast flow flux measurement using the LSCI. The novel technique also overcomes LSCI's biggest shortcoming, which is high sensitivity to artifact movement. An adhesive opaque patch (AOP) is introduced for satisfactory recording of microcirculatory blood flow, by subtracting the LSCI signal from the AOP from the laser speckle skin signal. The optimal setting is also defined because the LSCI is most powerful when flux changes are measured relative to a reference baseline, with blood microcirculatory flux expressed as a percentage change from the baseline. These changes may be used for analyzing the status of the blood flow system.

Stair negotiation as a rehabilitation intervention for enhancing recovery following total hip and knee replacement surgery.

BACKGROUND: Total hip replacement (THR) and total knee replacement (TKR) are common orthopaedic procedures. However, an optimal programme for post-operative rehabilitation has yet to be established. Stair negotiation is a challenging, habitual task, regularly used as a post-operative functional outcome measure; yet as a physical rehabilitation intervention it appears to be rarely used. AIM: The review purpose was to investigate the effectiveness of stair climbing as a rehabilitation intervention for THR and TKR patients. METHODS: MEDLINE, PsycINFO, Science Citation Index, CINAHL, SPORTDiscus and the Cochrane Database of Systematic Reviews were searched. The systematic review targeted studies using stair negotiation as a rehabilitation intervention. Randomised and non-randomised controlled trials, pilot studies, and case studies were included; systematic reviews and meta-analyses were excluded. RESULTS: Of 650 articles identified, ten studies were eligible for review. A predefined data table to extract information from selected studies was used. Of the ten identified reports, two prehabilitation and eight rehabilitation studies included stair negotiation exercises as part of multi-modal physical interventions. Outcome measures were classified as: functional self-reported, perceptual, psychological and those relating to quality of life. CONCLUSION: Studies were methodologically heterogeneous and typically lacked adequate control groups. It was not possible to determine the impact of stair negotiation exercise on the positive outcomes of interventions. Stair negotiation warrants further investigation as a rehabilitation activity.

The effect of calf neuromuscular electrical stimulation and intermittent pneumatic compression on thigh microcirculation.

OBJECTIVE: This study compares the effectiveness of a neuromuscular electrical stimulation (NMES) device and an intermittent pneumatic compression (IPC) device on enhancing microcirculatory blood flow in the thigh of healthy individuals, when stimulation is carried out peripherally at the calf. MATERIALS AND METHODS: Blood microcirculation of ten healthy individuals was recorded using laser speckle contrast imaging (LSCI) technique. A region of interest (ROI) was marked on each participant thigh. The mean flux within the ROI was calculated at four states: rest, NMES device with visible muscle actuation (VMA), NMES device with no visible muscle actuation (NVMA) and IPC device. RESULTS: Both NMES and IPC devices increased blood flow in the thigh when stimulation was carried out peripherally at the calf. The NMES device increased mean blood perfusion from baseline by 399.8% at the VMA state and 150.6% at the NVMA state, IPC device increased the mean blood perfusion by 117.3% from baseline. CONCLUSION: The NMES device at VMA state increased microcirculation by more than a factor of 3 in contrast to the IPC device. Even at the NVMA state, the NMES device increased blood flow by 23% more than the IPC device. Given the association between increased microcirculation and reduced oedema, NMES may be a more effective modality than IPC at reducing oedema, therefore further research is needed to explore this.

A cycling and education programme for the treatment of hip osteoarthritis: a quality improvement study.

Osteoarthritis of the hip is associated with pain, stiffness and limitations to activities of daily living. The aims of this quality improvement project were to introduce a service developed to promote the self-management of hip osteoarthritis through exercise and education and to assess the impact of the programme on pain, function and quality of life. The service was a six-week cycling and education programme and 119 participants took part. Statistically significant improvements were found for Oxford Hip Scores (Mean (SD) change 4.14, 95%, CI 3.02, 5.25, p < 0.001); Sit-to-stand scores (mean change 3.06, 95%, CI 2.33, 3.79, p < 0.001); EQ5D-5L Utility (mean change 0.06, 95%, CI 0.03, 0.09, p < 0.001); EQ5D VAS (mean change 7.05, 95%, CI 4.72, 9.39, p < 0.001); pain on weight-bearing (WB) (mean change 1.56, 95%, CI 0.77, 2.36, p < 0.001), HOOS function (median change (IQR) 7.35, 1.84 to 19.12, p < 0.001) and TUG test (median change 1.11, 0.31 to 2.43, p < 0.001). Participants reported improvements in pain and function; increased confidence in managing hip pain and an increase in motivation to exercise. These findings were supported by a patient and public involvement forum who suggested extending the programme to eight weeks. These results suggest that the service has potential in the management of hip osteoarthritis.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery.

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.