Summary of the best evidence for early mobilization after lumbar spinal fusion surgery: a systematic review

Abstract

Purpose

This study aimed to systematically identify, critically appraise, and synthesize the highest-quality evidence on early mobilization following lumbar spinal fusion surgery (LSF), thereby establishing an evidence-based framework to guide clinical nursing practice.

Methods

Following the 6 S evidence model, we performed a comprehensive literature search across multiple databases and gray literature sources up to December 2024. Studies investigating early postoperative mobilization in LSF patients were screened for eligibility and rigorously assessed for methodological quality. Relevant evidence was extracted, categorized, and synthesized to develop evidence-based clinical recommendations.

Results

Twenty-eight studies met the inclusion criteria, including 1 best practice guideline, 4 clinical guidelines, 6 systematic reviews, 1 evidence summary, 6 expert consensus statements, 4 randomized controlled trials (RCTs), and 6 cohort studies. Based on the synthesized evidence, 22 clinical recommendations were formulated, categorized into five key domains: Multidisciplinary collaboration and individualized activity planning, Patient-centered health education, Pre-ambulation functional assessment, Activity protocols and progression criteria, and Safety monitoring and risk mitigation strategies.

Conclusion

This evidence synthesis provides a standardized framework for early mobilization following LSF surgery. Implementation should be adapted to institutional resources and patient-specific factors, with continuous monitoring of clinical outcomes to ensure efficacy and safety.

Introduction

Lumbar Spinal Fusion (LSF) is a widely adopted surgical procedure for managing debilitating degenerative spinal conditions, including lumbar disc herniation, spinal stenosis, degenerative spondylolisthesis, and adult degenerative scoliosis. The progression of these degenerative pathologies is accelerated by risk factors such as advanced age, very high levels of physical activity [1], and obesity [2, 3], leading to clinical manifestations that commonly include low back pain, lower extremity numbness, muscle weakness, intermittent claudication, and other symptoms of neurological impairment. In severe cases, patients may experience bowel/bladder dysfunction and sexual impairment, making it one of the leading causes of disability [4]. For patients who do not respond to conservative treatment, LSF may be indicated. The technical approach varies depending on surgical indications and surgeon preference, but the fundamental objective remains consistent: to perform a laminectomy (or equivalent) or discectomy followed by arthrodesis of two or more vertebral segments. This aims to alleviate neural compression, reduce pain, prevent further neurological deterioration, and enhance functional outcomes [5]. Common surgical techniques include posterior approaches such as Transforaminal Lumbar Interbody Fusion (TLIF) and Posterior Lumbar Interbody Fusion (PLIF), which enable decompression and fusion through a single posterior access, and anterior approaches such as Anterior Lumbar Interbody Fusion (ALIF), which affords superior intervertebral disc space visualization but necessitates an abdominal incision. Furthermore, the complexity can ranges from single-level fusion for focal pathology to multi-level instrumented for deformity correction [6]. Research indicates a 62.3% increase in LSF procedures over the past decade [7]. However, its clinical superiority remains contentious. Several systematic reviews have reported no significant benefit for the addition of fusion compared to decompression alone in patients with lumbar spinal stenosis with or without spondylolisthesis [8, 9], though contradictory findings exist [10]. Similarly, evidence supporting the addition of fusion to discectomy for lumbar disc herniation remains inconclusive [11, 12]. Therefore, the decision to perform fusion must be carefully individualized based on specific clinical indications. Due to its invasive nature involving significant bone structure disruption and potential neural tissue damage, LSF frequently induces substantial physiological and psychological stress responses in patients, with postoperative pain being particularly prominent [13]. Many patients develop kinesiophobia (fear of movement), leading to refusal of early rehabilitation exercises and mobilization, consequently delaying recovery and compromising quality of life - outcomes that contradict preoperative expectations [14, 15]. The evidence regarding early postoperative mobilization must be interpreted within this heterogeneous context—encompassing diverse pathologies, surgical techniques, and patient populations (e.g., the elderly with comorbidities vs. younger patients with single-level pathology)—that the evidence regarding early postoperative mobilization exists. Although early mobilization is a well-established component of Enhanced Recovery After Surgery (ERAS) protocols and has been shown to facilitate recovery, decrease complications, and reduce length of hospital stay [16, 17], its implementation following LSF lacks standardization and contentious [18]. For the purpose of this review, ‘early mobilization’ is operationally defined as any prescribed physical activity—ranging from pre-ambulation exercises (e.g., bed mobility, sitting upright, standing) to walking—initiated within the first postoperative week. Critical practical aspects—such as optimal timing, activity progression, contraindications, and strategies to overcome barriers like pain and kinesiophobia—remain poorly synthesized in the literature. This gap between generalized principle and specific, evidence-based practice creates uncertainty and variability in care. Thus, this systematic review seeks to synthesize the best available evidence to develop practical guidance on implementing early mobilization that is applicable across the wide clinical spectrum of LSF patients.

Materials and methods

Problem formulation

The PIPOST framework [19] serves as a vital tool in evidence-based practice (EBP) and evidence-based nursing (EBN), offering a structured approach for formulating clinical questions—particularly those pertaining to evidence implementation and quality improvement initiatives. By systematically defining key components, PIPOST facilitates a comprehensive and efficient search for evidence while supporting its practical application. In accordance with this framework, the evidence-based question in this study was developed using PIPOST: Population (P): Patients undergoing lumbar fusion surgery for degenerative lumbar spine disease. Intervention (I): Early mobilization interventions. Persons (P): Healthcare professionals (clinical staff). Outcomes (O): Time to first postoperative ambulation, Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for pain, Short Form-36 (SF-36) Health Survey scores, postoperative complication rates, and length of hospital stay. Setting (S): Orthopedic ward. Type of evidence (T): Evidence resources including best practices, guidelines, evidence summaries, systematic reviews, expert consensus, and high-quality original studies.

Search approach and strategy

We employed a top-down retrieval strategy based on the 6S Evidence Pyramid Model to identify the highest level of available evidence. The model is a hierarchical model designed to help healthcare professionals, researchers, and students efficiently find the current best available evidence for clinical decision-making. Where each “S” represents a type of evidence resource and is from the top of the tower to the bottom are computerized decision support system(CDSS), summaries, synopses of syntheses, syntheses, synopses of studies, studies. This study systematically searched multiple databases including BMJ Best Practice, UpToDate, Cochrane Library, Guidelines International Network (GIN), National Guideline Clearinghouse (NGC), Registered Nurses’ Association of Ontario (RNAO), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), Medsci, North American Spine Society (NASS), The Spine Society of Europe (EUROSPINE), ERAS Society, International Collaboration of Orthopaedic Nursing (ICON), Joanna Briggs Institute (JBI) EBP Database, CINAHL, PubMed, Embase, Web of Science, CNKI, CBM, Wanfang, and VIP databases for best practices, guidelines, expert consensus, evidence summaries, systematic reviews, and high-quality primary studies related to early mobilization after lumbar fusion surgery. A comprehensive search strategy combining MeSH terms and free-text terms was employed, with English keywords including “spinal fusion"、"lumbar fusion"、“lumbar spinal fusion”、“lumbar fusion surgery”、“spondylodesis”、“spondylodeses”、“spondylosyndesis”、“spondylosyndeses”、“early ambulation”、“early mobilization”、“postoperative rehabilitation”、“enhanced recovery after surgery”、“early rehabilitation”、“exercise”、“mobilization”、“rehabilitation”.The PubMed search strategy was (“spinal fusion“[MeSH Terms] OR “lumbar fusion“[Title/Abstract] OR"lumbar spinal fusion“[Title/Abstract] OR “lumbar fusion surgery“[Title/Abstract] OR “spondylosyndesis“[Title/Abstract]) AND (“early ambulation“[MeSH Terms] OR “early mobilization“[Title/Abstract] OR “postoperative rehabilitation“[Title/Abstract] OR “enhanced recovery after surgery“[MeSH Terms] OR “early rehabilitation“[Title/Abstract] OR “exercise“[MeSH Terms] OR “mobilization“[Title/Abstract] OR “rehabilitation“[MeSH Terms]).The search timeframe covered records from database inception to December 2024.

Inclusion and exclusion criteria for literature

Inclusion criteria for this study were (1) Studies involving adult patients undergoing lumbar fusion surgery for degenerative spinal conditions, including lumbar disc herniation, spinal stenosis, degenerative spondylolisthesis, and degenerative scoliosis; (2) Research focusing on early mobilization interventions; (3) Publication types including best practice, guidelines, evidence summaries, systematic reviews, expert consensus, and high-quality primary studies; (4) Publications in Chinese and/or English only. Exclusion criteria were (1) Incomplete records or unavailable full-text publications; (2) Secondary analyses (e.g., guideline interpretations or commentary articles); (3) Non-research documents (e.g., protocols, reports, or draft versions);

(4) Duplicate publications or studies superseded by updated evidence; (5) Primary studies already incorporated into systematic reviews or guidelines.

Literature quality assessment

The included guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument [20]. Systematic reviews, expert consensus statements, cohort studies, and randomized controlled trials (RCTs) were assessed using the corresponding Joanna Briggs Institute (JBI) Critical Appraisal Tools [19] for systematic reviews, expert consensus, cohort studies, and RCTs, respectively. Best practice recommendations and evidence summaries were appraised by tracing their original sources and applying the appropriate JBI evaluation tool based on the study design of the primary literature.

Evidence extraction, integration, and summarization

Two team members trained in evidence-based nursing independently conducted literature quality assessment and evidence extraction. In cases of disagreement, a third expert was consulted for arbitration to reach a final decision. The extracted evidence was systematically collated and synthesized. When conflicting conclusions arose from different evidence sources, strict prioritization principles were applied: (1) preference for evidence-based sources, (2) higher-quality evidence taking precedence, and (3) Based on the impact factor and ranking of the journal, the research design and level of evidence, the sample size and statistical power, as well as the citation frequency, priority is given to the recently published literature. This rigorous process ensured the most reliable and up-to-date evidence was incorporated into the analysis.

Evidence grading

The included evidence was graded according to the JBI (2014) Evidence Pre-grading System by tracing back to the original sources. Evidence levels were classified from Level 1 (highest) to Level 5 (lowest), with more specific classifications as follows:

• Level 1a: systematic review of multiple RCTs;

• Level 1b: systematic review of multiple RCTs and other intervention studies;

• Level 1c: single randomized controlled trial;

• Level 1d: quasi-randomized controlled trial;

• Level 2a: systematic review of multiple types of experimental studies;

• Level 2b: systematic review of multiple types of experimental studies and other low-quality intervention studies;

• Level 2c: single-arm prospective study with a control group (a type of experimental study);

• Level 2d: experimental study involving a before–after comparison or a retrospective comparative study;

• Level 3a: systematic review of multiple cohort studies;

• Level 3b: systematic review of multiple cohort studies and other low-quality observational studies;

• Level 3c: cohort study with a control group;

• Level 3d: single-case case–control study;

• Level 3e: observational study without a control group;

• Level 4a: systematic review of multiple descriptive studies;

• Level 4b: single cross-sectional study;

• Level 4c: case series study;

• Level 4d: case study;

• Level 5a: systematic evaluation of expert opinions;

• Level 5b: expert consensus;

• Level 5c: basic research and individual expert opinions.

Results

General characteristics of included literature

The initial search yielded 10,733 potentially relevant articles. After removing duplicates, 6,860 records remained. Following a review of titles and abstracts, 377 articles were retained as potentially eligible. After full-text assessment, studies with unavailable full texts or low methodological quality were excluded, resulting in the final inclusion of 28 articles (Fig. 1). The breakdown of included literature was as follows:1 best practice [21], 4 clinical guidelines [16, 22–24], 1 evidence summary [25], 6 systematic reviews [26–31], 6 expert consensus statements [32–37], 4 randomized controlled trial [38–41], and 6 cohort studies [42–47]. The general characteristics of the included studies are presented in Table 1.

Fig. 1.

Flowchart of literature screening

Table 1.

General characteristics of the included literatures (n = 28)

Author	Literature reference	The literature theme	Type of literature	Year of publication
Bogaert et al. [21]	Pubmed	Best practice rehabilitation pathway for the management of single and double-level lumbar fusion surgery: a modified Delphi Study	Best Practice	2023
CARM [22]	MedLive	Guidelines for the prevention of osteoporosis-related complications following lumbar fusion and internal fixation (2024)	Guideline	2024
CAOS [23]	MedLive	Guidelines for multidisciplinary management of common perioperative issues in elderly spine surgery patients	Guideline	2023
CARM [24]	Wanfang Data	Guideline for diagnosis treatment and rehabilitation of lumbar disc herniation	Guideline	2022
Debono et al. [16]	BMJ Best Practice	Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS) Society recommendations	Guideline	2021
Yu et al. [25]	CNKI	Summary of best evidence for early ambulation in patients undergoing open lumbar surgery	Summary of evidence	2024
Han et al. [26]	CNKI	Postoperative bracing on clinical outcomes following posterior lumbar fusion for degenerative lumbar diseases: a meta analysis	Systematic review	2023
Bogaert et al. [27]	Web Of science	Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis	Systematic review	2022
Ozden [28]	Web Of science	The Effectiveness of Physical Exercise After Lumbar Fusion Surgery: A Systematic Review and Meta-Analysis	Systematic review	2022
Gong et al. [29]	CNKI	Effect of functional exercise versus conventional intervention on clinical outcomes of lumbar surgeries: a meta analysis	Systematic review	2019
Madera et al. [30]	Web Of science	The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review	Systematic review	2017
Greenwood et al. [31]	Web Of science	Rehabilitation Following Lumbar Fusion Surgery: A Systematic Review and Meta-Analysis	Systematic review	2016
Meyrat et al. [33]	Pubmed	Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review	Expert consensus	2023
CARM [32]	CNKI	Expert consensus on the implementation of enhanced recovery after surgery in spinal fusion surgery for advanced age patients	Expert consensus	2023
Bai et al. [34]	CNKI	Enhanced recovery after surgery for degenerative scoliosis: consensus on perioperative management strategy	Expert consensus	2020
Zhang et al. [35]	CNKI	Expert consensus on the implementation of enhanced recovery after surgery in posterior short-segment lumbar surgery	Expert consensus	2019
Sun et al. [36]	CNKI	Expert consensus on the implementation of enhanced recovery after surgery in posterior long-segment lumbar surgery	Expert consensus	2019
Sun et al. [37]	VIP Database	Expert consensus in enhanced recovery after spinal surgery in China: perioperative management	Expert consensus	2017
EM et al. [38]	Sinomed	Enhanced Recovery after Lumbar Spine Fusion: A Randomized Controlled Trial to Assess the Quality of Patient Recovery	RCTs	2020
Skrobot et al. [39]	Web Of science	Early Rehabilitation Program and Vitamin D Supplementation Improves Sensitivity of Balance and the Postural Control in Patients after Posterior Lumbar Interbody Fusion: A Randomized Trial	RCTs	2019
Kernc et al. [40]	Web Of science	Early initiation of a strength training based rehabilitation after lumbar spine fusion improves core muscle strength: a randomized controlled trial	RCTs	2018
Chen et al. [41]	Web Of science	Is rehabilitation intervention during hospitalization enough for functional improvements in patients undergoing lumbar decompression surgery? A prospective randomized controlled study	RCTs	2015
Halvorson et al. [44]	Pubmed	Multi-domain biopsychosocial postoperative recovery trajectories associate with patient outcomes following lumbar fusion	Cohort study	2023
Fiasconaro et al. [46]	Pubmed	Enhanced Recovery Implementation and Perioperative Outcomes in Posterior Fusion Patients	Cohort study	2020
Wang et al. [42]	Pubmed	Safety and benefit of ambulation within 24 h in elderly patients undergoing lumbar fusion: propensity score matching study of 882 patients	Cohort study	2024
Wang et al. [43]	Pubmed	Association between delayed ambulation and increased risk of adverse events after lumbar fusion surgery in elderly patients	Cohort study	2024
Gilmore et al. [47]	Pubmed	Predictors of substantial improvement in physical function six months after lumbar surgery: is early post-operative walking important? A prospective cohort study	Cohort study	2019
Huang et al. [45]	Pubmed	Benefits of Early Ambulation in Elderly Patients Undergoing Lumbar Decompression and Fusion Surgery: A Prospective Cohort Study	Cohort study	2021

Literature quality assessment results

Guidelines

This study included a total of 4 clinical guidelines, with 2 guidelines [16, 22] rated as Grade A (recommended for clinical practice with modifications) and 2 guidelines [23, 24] rated as Grade B (recommended with reservations). The standardized scores of each domain were 80.56%−100% for scope and purpose, 52.78%−77.78% for stakeholder involvement, 36.46%−93.75% for rigor of development, 63.89%−94.44% for clarity of vision, 31.25%−79.17% for applicability, and 25%−87.50% for editorial independence. All guidelines were ultimately retained for inclusion in the evidence synthesis. The quality assessment results are presented in Table 2.

Table 2.

Methodological quality assessment of included guidelines

Guidelines	Standardization Percentage for Each Field (%)						Overall Quality	Recommendation	≥ 60%	≥ 30%	Level
	Scope and	Participants	Rigor	Clarity	Applicability	Independence	Ratings (scores)		Number	Number
	Purpose								of Fields	of Fields
CARM [22]	100%	77.78%	93.75%	91.67%	60.42%	87.50%	6	YES	6	6	A
CAOS [23]	88.89%	52.78%	36.46%	63.89%	31.25%	79.17%	4	YES	3	6	B
CARM [24]	80.56%	52.78%	80.21%	88.89%	54.17%	58.33%	4	YES	3	6	B
Debono et al. [16]	94.44%	66.67%	77.08%	94.44%	79.17%	25%	5	YES	5	5	A

Systematic review

A total of 6 systematic reviews were included in this study. Among them:

1 systematic review [29] was rated as “unclear” for Item 5 (“Was the literature quality assessment criteria appropriate?“) and “no” for Item 7 (“Were measures taken to minimize errors in data extraction?“), while all other items were rated as “yes.” 3 systematic reviews [27, 28, 31] were rated as “no” for Item 7 (data extraction error minimization), with all other items rated as “yes.“1 systematic review [26] was rated as “no” for Item 4 (“Were the literature search databases/resources sufficiently comprehensive?“), with all other items rated as “yes.“1 systematic review [30] was rated as “yes” for all items, indicating high methodological quality. All 6 systematic reviews were ultimately included in the evidence synthesis. The quality assessment results are presented in Table 3.

Table 3.

JBI scores of included systematic reviews

Items	Han et al[26]	Bogaert et al[27]	Ozden [28]	Gong et al[29]	Madera et al[30]	Greenwood et al[31]
1.Is the review question clearly and explicitly stated?	Yes	Yes	Yes	Yes	Yes	Yes
2.Were the inclusion criteria appropriate for the review question?	Yes	Yes	Yes	Yes	Yes	Yes
3.Was the search strategy appropriate?	Yes	Yes	Yes	Yes	Yes	Yes
4.Were the sources and resources used to search for studies adequate?	No	Yes	Yes	Yes	Yes	Yes
5.Were the criteria for appraising studies appropriate?	Yes	Yes	Yes	Unclear	Yes	Yes
6.Was critical appraisal conducted by two or more reviewers independently?	Yes	Yes	Yes	Yes	Yes	Yes
7.Were there methods to minimize errors in data extraction?	Yes	No	No	No	Yes	No
8.Were the methods used to combine studies appropriate?	Yes	Yes	Yes	Yes	Yes	Yes
9.Was the likelihood of publication bias assessed?	Yes	Yes	Yes	Yes	Yes	Yes
10.Were recommendations for policy and/or practice supported by the reported data?	Yes	Yes	Yes	Yes	Yes	Yes
11.Were the specific directives for new research appropriate?	Yes	Yes	Yes	Yes	Yes	Yes

Expert consensus

A total of 6 expert consensus [32–37] were included, all of which were rated as “unclear” for Item 6 (“Were any discrepancies between the proposed recommendations and previous literature explicitly addressed?“), while all other items were rated as “yes.” Given their overall high quality, all were retained for inclusion. The quality assessment results are presented in Table 4.

Table 4.

JBI scores of included expert consensus

Items	Meyrat et al[33]	CARM [32]	Bai et al[34]	Zhang et al[35]	Sun et al[36]	Sun et al[37]
1.Is the source of the opinion clearly identified?	Yes	Yes	Yes	Yes	Yes	Yes
2.Does the source of the opinion have standing in the field?	Yes	Yes	Yes	Yes	Yes	Yes
3.Are the interests of the relevant population the central focus of the opinion?	Yes	Yes	Yes	Yes	Yes	Yes
4.Is the opinion’s basis in logic, experience or theory clearly argued?	Yes	Yes	Yes	Yes	Yes	Yes
5.Is the argument leading to the opinion clear?	Yes	Yes	Yes	Yes	Yes	Yes
6.Is there any evidence of influence from vested interests on the opinion?	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear

Randomized controlled trials

A total of 4 randomized controlled trials were included, of which one article [39] was “no” for item 6 “whether the outcome assessor was blinded”, “no” for item 8 “whether the follow-up was complete, if not complete, whether measures were taken to deal with the loss of follow-up”, and “yes” for the rest. One article [41] answered “no” for item 2 “whether allocation concealment was achieved”, “no” for item 6 “whether outcome evaluators were blinded”, and “yes” for the rest. One article [40] answered “no” for item 2 “whether allocation concealment was achieved”, and “no” for item 6 “whether outcome evaluators were blinded”. Item 9 “Whether to include all randomly assigned research subjects in the outcome analysis” was “no”, and the rest were “yes”. All items in one article [38] were “yes”. All 4 RCTs were included in the final analysis. The quality assessment results are presented in Table 5.

Table 5.

JBI scores of included randomized controlled trials

Items	EM et al[38]	Kernc et al[40]	Skrobot et al[39]	Chen et al[41]
1.Was true randomization used for assignment of participants to treatment groups?	Yes	Yes	Yes	Yes
2.Was allocation to treatment groups concealed?	Yes	No	Yes	No
3.Were treatment groups similar at the baseline?	Yes	Yes	Yes	Yes
4.Were participants blind to treatment assignment?	Yes	Yes	Yes	Yes
5.Were those delivering treatment blind to treatment assignment?	Yes	Yes	Yes	Yes
6.Were outcomes assessors blind to treatment assignment?	Yes	No	No	No
7.Were treatment groups treated identically other than the intervention of interest?	Yes	Yes	Yes	Yes
8.Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?	Yes	Yes	No	Yes
9.Were participants analyzed in the groups to which they were randomized?	Yes	No	Yes	Yes
10.Were outcomes measured in the same way for treatment groups?	Yes	Yes	Yes	Yes
11.Were outcomes measured in a reliable way?	Yes	Yes	Yes	Yes
12.Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes
13.Was the trial design appropriate, and were any deviations from the standard RCTs design?	Yes	Yes	Yes	Yes

Cohort study

Six cohort studies were included. Among them, 3 articles [43, 45, 46] answered “no” in item 6, “Whether to describe reexposure or the observation outcome of the study subjects at the beginning of the study”, and the rest answered “yes”. Among them, 3 articles [42, 44, 47] were “unclear” for item 6, “whether to describe re-exposure or that the study subjects did not have observed outcomes at the beginning of the study”, “no” for item 10, “whether measures were taken to deal with loss to follow-up”, and “yes” for the rest. Despite minor limitations, all 6 cohort studies were deemed sufficiently rigorous for inclusion. The quality assessment results are presented in Table 6.

Table 6.

JBI scores of included cohort study

Items	Halvorson et al[44]	Fiasconaro et al[46]	Wang et al[42]	Wang et al[43]	Gilmore et al[47]	Huang et al[45]
1.Were the two groups similar and recruited from the same population?	Yes	Yes	Yes	Yes	Yes	Yes
2.Were the exposures measured similarly to assign people to both exposed and unexposed groups?	Yes	Yes	Yes	Yes	Yes	Yes
3.Was the exposure measured in a valid and reliable way?	Yes	Yes	Yes	Yes	Yes	Yes
4.Were confounding factors identified?	Yes	Yes	Yes	Yes	Yes	Yes
5.Were strategies to deal with confounding factors stated?	Yes	Yes	Yes	Yes	Yes	Yes
6.Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)?	Unclear	No	Unclear	No	Unclear	No
7.Were the outcomes measured in a valid and reliable way?	Yes	Yes	Yes	Yes	Yes	Yes
8.Was the follow up time reported and sufficient to be long enough for outcomes to occur?	Yes	Yes	Yes	Yes	Yes	Yes
9.Was follow up complete, and if not, were the reasons for loss to follow up described and explored?	Yes	Yes	Yes	Yes	Yes	Yes
10.Were strategies to address incomplete follow up utilized?	No	Yes	No	Yes	No	Yes
11.Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes	Yes	Yes

Other literature

1 best practice guideline [21] was included. Upon tracing its original sources, the foundational evidence was derived from an expert consensus (Delphi study). The original study was critically appraised using the JBI Critical Appraisal Checklist for Expert Consensus, confirming high methodological quality, thus warranting inclusion.1 evidence summary [25] was included. After reviewing its primary sources, the summary integrated:1 clinical guideline,1 expert consensus,2 randomized controlled trials (RCTs).All original studies underwent rigorous quality assessment using corresponding JBI appraisal tools and were judged to be of high quality, supporting the inclusion of the evidence summary.

Evidence summary

Finally, 22 pieces of evidence were extracted and summarized from the five aspects of multidisciplinary collaboration and personalized activity planning, health education, activity evaluation, activity content and safety management, as shown in Table 7.

Table 7.

Best evidence for early mobilization in patients after lumbar fusion surgery

Category	Evidence Content	Evidence Level	Notes
Multidisciplinary Collaboration and Personalized Activity Planning	1.A multidisciplinary team was assembled, comprising surgeons, anesthesiologists, ward and operating room nurses, rehabilitation physicians, and dietitians. The team implemented clear role delineation and collaborated with patients and their families to formulate a goal-oriented, phased, and individualized early ambulation protocol. Regular interdisciplinary communication was maintained to ensure coordinated implementation [25]	1c	Focus on open lumbar surgery
	2.Targeted psychological nursing interventions should be developed based on individual recovery trajectories to optimize patients’ mental health outcomes [24, 28, 44]	1a
	3.For postmenopausal women and men aged 65 years or older, bone mineral density (BMD) assessment should be performed during the perioperative period. Patients diagnosed with osteoporosis require individualized guidance on postoperative rehabilitation timing and exercise modalities [22]	1a	Focus on prevention of osteoporosis
Health Education	4.Pain education, functional mobility training (standing, transfers, gait rehabilitation), and ergonomic recommendations were delivered through multimodal approaches (e.g., leaflets, videos) [21]	5b	Include single and double-level lumbar fusion surgery
	5.Preoperative Education: ERAS Protocol, Surgical Procedure and Prognosis, Core Strength/Cardiorespiratory Fitness Training, and Self-Assessment Methods. Alleviating Anxiety and Fear to Promote Treatment Adherence [32, 35]	5b	Focus on elderly patients
	6.Postoperative Education: Enhancing Self-Management and Gradual Activity Progression. Ensuring Continuity of Rehabilitation Goals and Interventions During Hospitalization and After Discharge, with Structured Follow-Up [41]	1c
	7.Lifestyle Modification Guidelines: Appropriate Exercise, Weight Control, Enhanced Self-Protection Awareness, and Avoidance of Poor Lumbar Postures to Facilitate Low Back Pain Rehabilitation [24]	1c	Focus on lumbar disc herniation
Mobility Assessment	8.Early mobilization is recommended for all patients undergoing lumbar decompression and fusion surgery, unless contraindicated by complications such as cerebrospinal fluid leakage [45]	3c	Focus on elderly patients
	9.Pain and Functional Assessments: The visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) score, and Oswestry Disability Index (ODI) were used to evaluate low back/leg pain and functional status at the following time points: 1 day preoperatively, at discharge, and at 1, 3, and 6 months post-discharge [35]	1c	Includes short-segment lumbar surgery
	10.Psychological Assessment: For patients with chronic pain or a history of anxiety/depression, the Hospital Anxiety and Depression Scale (HADS) may be used for evaluation and intervention planning [28, 35]	1a	Focus on chronic pain or a history of anxiety/depression
	11.Gait Assessment: Record the patient’s step count, walking distance, and duration during ambulation, including the time taken to transfer from bed to chair [43]	3c
Activity Content Assessment	12.Phased Postoperative Rehabilitation Protocol: Early-stage respiratory and transfer training, followed by progressive ambulation, lower extremity and core strengthening in intermediate/late phases, with standardized functional assessments [24]	1c
	13.Postoperative mobilization should be encouraged based on the patient’s wound condition, drainage status, and pain level. If ambulation is not feasible, early in-bed exercises (e.g., limb movement and turning practice) should be initiated promptly [35, 36]	5b	Focus on prevention of osteoporosis
	14.Early postoperative mobilization (including ankle pump exercises) should commence on the operative day, coupled with transfer training [34], For patients at high thrombotic risk, low-molecular-weight heparin (LMWH) prophylaxis is recommended starting 24 h postoperatively [36]	1c	Includes long-segment lumbar surgery
	15.Postoperative physical therapy should be initiated from the second postoperative day, incorporating trunk and lower extremity strengthening exercises, stretching regimens, gait assessment, and a progressive walking program with gradual increases in both duration and frequency of ambulation [47]	3d	Focus on elderly patients
	16.Patients are encouraged to initiate active mobilization one week postoperatively, primarily consisting of ambulation at self-tolerated distances.A daily 30-minute rehabilitation regimen should be implemented, focusing on spinal postural alignment and stabilization exercises [41]	1c
	17.Early mobilization should be performed while maintaining lumbar neutral alignment to stabilize the lumbopelvic complex and minimize mechanical strain on the fused segments [39]	1c
	18.Essential components of early ambulation care include preoperative education, fluid management, early catheter removal, nutritional support, and analgesia [42, 43]	3c
Safety Management	19.During early postoperative mobilization, fall prevention measures should be implemented, while patients with osteoporosis should maintain ongoing anti-osteoporotic therapy [23]	1c	Focus on elderly patients
	20.Ambulation should be assisted by family members or nursing staff with close monitoring for orthostatic hypotension. If symptoms of intolerance develop, patients should immediately return to supine position and reattempt mobilization after adequate rest [34]	5b	Primarily degenerative scoliosis
	21.Postoperative lumbar rehabilitation protocols should be strictly individualized, with training sessions optimally limited to < 60 min to prevent secondary injury [29]	1b
	22.Patients are advised to avoid trunk rotation, forward flexion, hyperextension, and cross-legged sitting positions during the initial 3-month postoperative period. Standardized follow-up assessments should be conducted at 1, 3, 6, 12, and 24 months postoperatively [34]	5b	Primarily degenerative scoliosis

Discussion

The following discussion synthesizes the retrieved evidence to formulate broad, evidence-based recommendations for early mobilization following LSF. It is imperative to preface that these recommendations are intended to provide a general framework and set of principles to guide practice. Their successful implementation in any specific clinical setting will not be rigid but must be adaptable and thoughtfully tailored. The ultimate application of these guidelines will inevitably be influenced and modified by a multitude of local factors, including available personnel (e.g., physiotherapist-to-patient ratios, nursing expertise), institutional resources and protocols (e.g., availability of specialized equipment, EHR integration), and most importantly, individual patient case-mix (e.g., age, comorbidity burden, surgical complexity, and psychological factors such as kinesiophobia).

The early mobilization of patients after lumbar fusion requires multidisciplinary collaboration and individualized activity plans

The Multidisciplinary Team (MDT) plays a pivotal role in the successful implementation of early mobilization following lumbar fusion surgery. Establishing a patient-centered MDT model is essential. By integrating multi-professional expertise and multidimensional assessment—including patient demographics, surgical techniques, postoperative recovery progress, and psychosocial factors—the responsibilities of each discipline can be clearly defined. The successful implementation of early mobilization requires a structured, multi-professional protocol with explicitly defined roles and responsibilities throughout the perioperative continuum. Each discipline contributes unique expertise at critical timepoints: Surgeons are responsible for determining the medical stability for ambulation based on intraoperative findings and surgical technique. They must specify procedure-specific weight-bearing restrictions and any contraindications to mobilization in the immediate postoperative orders; Anesthesiologists are responsible for optimizing rapid recovery from anesthesia, implementing a multimodal analgesia protocol to facilitate pain-controlled mobilization, and managing hemodynamic stability to enable early out-of-bed activity; Ward and Operating Room Nurses are responsible for coordinating pain management at the bedside, assisting with the first out-of-bed transfer, continuously assessing patient readiness and response to mobility, and documenting progress. They serve as the central communication hub between all disciplines and across shift changes; Rehabilitation Physicians and Physiotherapists are responsible for conducting preoperative functional assessments, educating patients on safe mobilization techniques (e.g., log-rolling, sit-to-stand) preoperatively, and leading the execution and progression of the postoperative mobilization protocol daily; Dietitians are responsible for conducting nutritional assessments to identify patients at risk of sarcopenia or malnutrition, and implementing targeted nutritional support to ensure patients have the necessary protein and energy reserves for functional recovery and mobilization. This structured role assignment ensures accountability, prevents critical task omission, and establishes an efficient communication network across disciplines, thereby creating a reproducible and clinically actionable pathway for implementing early mobilization protocols. Furthermore, an information-sharing platform facilitates real-time communication and data integration, enabling the collaborative development of personalized mobilization plans, thereby enhancing the systematic and precise execution of early mobilization protocols [48].Studies [49] indicates that the MDT approach significantly reduces time to first ambulation and positively influences postoperative functional recovery. Additionally, patients and their families should be actively engaged as core members of the decision-making team to ensure comprehensive postoperative support. This involvement not only improves treatment adherence and patient satisfaction but also serves as a critical factor in the effective implementation of early mobilization strategies.

The strong consensus regarding the necessity of an MDT approach is compelling and is supported predominantly by Level 1 evidence. The practical implementation of this model, however, is highly dependent on local institutional factors such as staffing ratios, skill mix, and technological infrastructure. Crucially, the effectiveness of role delineation may vary across different patient populations; for instance, the nutritional support led by dietitians is particularly critical in elderly, potentially malnourished patients undergoing multi-level fusion, whereas its role might be less pronounced in younger, healthier patients receiving single-level procedures. This underscores the need for adaptable, rather than rigid, protocolization.

Whole-course health education to improve the compliance of early mobilization in patients after lumbar fusion surgery

Based on our identification of patient-related barriers—including limited knowledge of early mobilization benefits, fear-related attitudes (kinesiophobia), and consequent poor adherence to mobilization protocols—as major impediments to successful implementation, we recommend adopting the KAP framework. This model provides a structured approach to address these specific domains: it targets educational deficits (Knowledge), modifies misconceptions and fears (Attitude), and promotes desired behaviors (Practice). The KAP framework can be operationalized through a timed, perioperative educational intervention: Preoperatively (Knowledge), a physiotherapist uses the Teach-Back method with visual aids to ensure patient comprehension. Intraoperatively (Attitude), the anesthesia or surgical team reinforces safety messages to address kinesiophobia. Postoperatively (Practice), nurses and physiotherapists provide just-in-time coaching during the first ambulation attempt. This creates a ‘closed-loop’ system where education is continuously assessed and reinforced, not a one-time event.We further propose the “teach-back” method as the optimal strategy for delivering knowledge within the KAP framework. Health education should facilitate bidirectional communication, as passive information transfer is often ineffective. Teach-back ensures comprehension by having patients restate instructions in their own words—a critical step in early mobilization protocols, where misunderstandings may lead to serious safety risks. This method must be tailored to patients’ cognitive and behavioral capacities, emphasizing interactive and personalized education to enhance engagement and self-management skills [50]. Integrating the KAP framework with the teach-back method offers a comprehensive, theory-driven solution to these challenges. By combining education with supportive strategies, healthcare providers can offer expert guidance, real-time feedback, and individualized recommendations, ultimately improving adherence to early mobilization protocols and accelerating recovery after lumbar fusion surgery.

However, the applicability of these educational strategies must be tailored to patient-specific factors. For example, the Teach-Back method may need significant adaptation for patients with lower health literacy or cognitive impairments, a common scenario in elderly cohorts. Thus, the evidence supports a principle of tailored education rather than a one-size-fits-all script.

Activity assessment is a necessary condition for early mobilization of patients after lumbar fusion surgery

The implementation of early mobilization following lumbar fusion surgery must be grounded in a comprehensive functional assessment. This evaluation serves to determine whether patients meet the criteria for early mobilization, thereby minimizing activity-related risks and preventing potential complications. Research [51] has demonstrated that patients’ psychological status and social support systems significantly influence both compliance with and outcomes of early mobilization protocols. By employing standardized assessment tools and evidence-based evaluation processes, clinicians can conduct multidimensional assessments to effectively identify high-risk patients and develop personalized intervention strategies. This approach establishes a dynamic “assessment-intervention-reassessment” management cycle that promotes sustained rehabilitation behavior modification. With advancements in artificial intelligence and big data analytics, intelligent assessment systems (such as AI-powered risk prediction models) are expected to provide more precise clinical decision support, thereby offering an evidence-based foundation for early mobilization protocols [52].

The critical role of pre-activity assessment is one of the most unanimously supported recommendations, drawing on Level 1–3 evidence concerning safety and risk mitigation. However, the specific assessment tools validated for the LSF population are scarce, and most recommendations are extrapolated from general surgical or geriatric literature. This gap is particularly relevant for complex cases, such as patients with adult degenerative scoliosis, where functional baselines and risks differ markedly from those with single-level stenosis.

The early mobilization of patients after lumbar fusion should follow the principle of a step by step ladder

Early mobilization following lumbar fusion surgery represents a critical element of Enhanced Recovery After Surgery (ERAS) protocols, significantly contributing to postoperative complication prevention and functional recovery. A phased rehabilitation approach should be implemented throughout the perioperative period, carefully tailored to each patient’s clinical status and recovery progression to ensure both safety and efficacy of early mobilization. The preoperative phase focuses on comprehensive patient education regarding the rationale for early mobilization, surgical procedures, and postoperative cooperation requirements. During the intraoperative phase, optimal surgical techniques, effective pain management, and complication prevention measures are prioritized to facilitate subsequent mobilization. Postoperatively, customized ambulation plans should be developed and executed according to individual patient needs, complemented by ongoing health education. This includes guidance on progressive mobilization exercises at designated time points and reinforcement of key ambulation principles, ultimately optimizing recovery outcomes through structured early mobilization [53].

The “step-by-step” principle is widely endorsed (Level 1–5 evidence), but the evidence defining the exact progression—especially time-to-next-step criteria—is heterogeneous and often vague. The optimal progression speed is likely not uniform but influenced by surgical factors (e.g., ALIF vs. TLIF, number of levels fused) and patient factors (e.g., age, pre-op fitness, presence of complications). For example, the evidence supporting rapid progression within 24 h is strongest for young, healthy patients undergoing single-level fusions, whereas the same protocol may be inappropriate for an elderly patient after a multi-level deformity correction. This evidence does not support a single protocol but rather a framework for clinical decision-making that must be individualized.

Safety management should be the core of early mobilization for patients after lumbar fusion surgery

Safety management permeates the entire early mobilization process, establishing a comprehensive safety chain encompassing assessment, planning, implementation, monitoring, and follow-up to ensure continuous patient safety during mobilization. Healthcare providers must conduct thorough risk assessments prior to patient mobilization, recognizing the crucial role of social support systems in facilitating early mobilization. The protocol requires: (1) provision of a secure mobilization environment, (2) close monitoring of vital signs and patient responses during activity, and (3) implementation of real-time surveillance with early warning mechanisms for prompt intervention and dynamic protocol adjustment. Post-ambulation evaluation and feedback should be performed, followed by scheduled reassessments and follow-up. These robust safety management measures effectively mitigate mobilization risks while enhancing intervention efficacy and sustainability, ultimately achieving an optimal equilibrium between rehabilitation benefits and safety considerations [54, 55].

The emphasis on safety is universally accepted and is supported by a logical synthesis of evidence from general surgery and specific complications in spine surgery (e.g., wound issues, falls). However, the highest levels of evidence (Level 1–2) from RCTs are often lacking for specific safety protocols in LSF. The recommended safety checks (e.g., vital sign monitoring) are considered standard practice based on Level 5 evidence. The key discussion point is that the threshold for stopping or modifying activity based on safety parameters is not well-defined by evidence and relies heavily on clinical judgment. This judgment, in turn, must be informed by the specific patient context, such as being more conservative with patients who have significant cardiopulmonary comorbidities or osteoporosis.

Limitations

A critical finding of our evidence synthesis is the significant heterogeneity observed among the included study populations. Notably, several studies focused exclusively on elderly patients, whose postoperative recovery patterns, bone quality, and complication profiles may differ substantially from those of younger individuals. As a result, recommendations derived predominantly from such studies may not be directly generalizable to a broader age demographic. Furthermore, our review integrated evidence from both single-level fusions and more complex procedures involving multi-level constructs or scoliosis. It is plausible that the physiological impact, risk profile, and optimal rehabilitation protocol for a two-level fusion due to spinal stenosis may differ considerably from those for a multi-level fusion performed to correct scoliosis. Therefore, the findings of this synthesis should be interpreted with careful consideration of these specific patient and surgical factors, and clinicians are encouraged to adapt the recommendations accordingly.

Furthermore, the scope of this synthesis is specifically centered on early mobilization following lumbar fusion procedures. The generalizability of the conclusions may be constrained by geographical, ethnic, and cultural differences in perioperative care pathways and patient adherence. Methodologically, the restriction of the literature search to English and Chinese databases may have resulted in the omission of pertinent studies published in other languages, potentially introducing language bias and limiting the global representativeness of the evidence base. Future studies should prioritize updating the current synthesis with more broadly representative data and refining clinical recommendations through structured evaluation of applicability, feasibility, efficacy, and patient-centered outcomes—thereby strengthening the foundation for evidence-based practice in diverse clinical contexts.

Conclusions

This study synthesizes the best available evidence regarding early mobilization following lumbar fusion surgery, addressing five critical dimensions: (1) multidisciplinary collaboration and personalized mobilization planning, (2) health education, (3) functional assessment, (4) activity protocols, and (5) safety management. The findings provide an evidence-based framework to guide clinical decision-making for postoperative lumbar fusion patients.

To translate these findings into practice, clinical medical staff should explicitly consider the following patient-specific factors and clinical scenarios:

Patient Characteristics: Comorbidity burden (e.g., cardiopulmonary diseases, osteoporosis), surgical factors (e.g., number of levels fused, approach, intraoperative complications), baseline functional status, and body mass index significantly influence ambulation capacity and risk. For instance, a frail patient with multi-level fusion and osteoporosis requires a more cautious protocol with closer safety monitoring (Dimension 5) compared to a robust patient with a single-level fusion.

Clinical Context: The timing of ambulation (Dimension 4) should be adapted based on the surgical closure integrity, drainage output, and pain levels. The content of health education (Dimension 2) should be personalized to the patient’s literacy level and cultural preferences. Functional assessment (Dimension 3) must utilize tools that are valid and feasible for the specific patient population served by the institution.

We recommend that healthcare providers use this framework not as a rigid protocol, but as a guide for developing optimal, patient-centered early mobilization protocols. Through comprehensive evaluation of evidence applicability and deliberate consideration of patient preferences and contexts, clinicians can maximize postoperative recovery outcomes.

Authors’ contributions

Ff W contributed to the design of the work and directed the writing of the manuscript, Ww C，Yq B contributed to the Literature retrieval, analysis and paper writing. Hl G，Ff D contributed to the the quality evaluation and summary of literature.L S contributed to collected the data. Qq C，Y C supervised the writing of and revision of the manuscript. All authors read and approved the final manuscript.

Funding

No.

Data availability

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

Declarations

Ethics approval and consent to participate

This study primarily relies on literature search and screening to extract relevant evidence, which is then summarized and integrated. Since the research process does not involve animals or humans, ethical review was not required.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.