Lumbar Fusion Rehabilitation

Indications

-Severe, disabling back or leg pain.

-Posttraumatic cases of segmental instability or potential neurologic injury

-Degenerative spinal pathology with failure of conservative treatment.

Degenerative cascade

Degenerative Disc Disease

Diagnosis:

Spinal radiographs showing:

-Osteophytes and segmental disc space narrowing in patients with degenerative spondylosis.

-A defect in the pars interarticularis

-Anterolisthesis, or a forward slippage of one vertebra on the next, is the hallmark radiographic finding in spondylolisthesis.

- Flexion and extension films can help to detect hypermobility or excessive motion in degenerative lumbar conditions

Types of lumbar fusion:

• The goal of a lumbar arthrodesis is the successful union of two or more vertebra
• Instrumentation can be used to immobilize the moving segments while the fusion becomes solid.
• Today, most spine surgeons use pedicle screw constructs to immobilize the vertebrae rigidly while preserving the normal lumbar lordosis 2

Posterolateral Lumbar Fusion:

-A midline posterior incision, with a laminectomy if necessary. -Transverse process, pars interarticularis, and if needed, the sacral alae are decorticated (posterior fusion). then a bone graft is placed on the decorticated surfaces.

Pedicle screws and rods or plates may be placed to immobilize the motion segments rigidly and augment the formation of a solid union.

- In routine cases of posterolateral fusions the disc is not radically resected. Biomechanical studies have shown that people bear load through the middle and posterior thirds of the disc. Several reports describe a persistently painful disc under a solid posterior fusion.14

Interbody Fusion:

A-posterior lumbar fusion (PLIF)

-Associated with a higher incidence of postsurgical nerve injuries.

D-Lateral Interbody Fusion

-Nerve stretch injury reported, with L4 nerve root injury most common.17

E-Interbody Cages

-Hollow cylinders made of titanium, carbon ,or bone filled with autogenous bone graft or a bone graft substitute and inserted between the vertebral bodies.

== SURGICAL PROCEDURE == 

Rehabilittion:

Preoperative phase

This is the proper timing for assessing functional outcomes and psychological support. this is possible through patient education, which includes:

• stabilization-based exercises
• Postoperative precautions
• Bed mobility and transfers
• Initial postoperative exercises
• Gait training with any necessary assistive devices
• Donning and doffing any required braces
• Wound care
• General overview and prognosis of the postoperative rehabilitation process

SURGICAL PROCEDURE

Video 

Rehabilittion:  

-individuals with more chronic pain symptoms will most likely exhibit altered pain processing, which may be addressed through including cognitive-behavioral interventions during the recovery process.

Preoperative phase

-conservative measures have not had a significant impact on the patient’s condition and that they have gone through an extensive therapy program.

- taught stabilization-based exercises and has begun to address other relevant physical and cognitive dysfunctions.

-preoperative management may be very useful in determining functionally relevant outcomes along with realistic goals.21 This is also the time to start on patient education regarding issues such as:

• Postoperative precautions

• Bed mobility and transfers

• Initial postoperative exercises

• Gait training with any necessary assistive devices

• Donning and doffing any required braces

• Wound care

• General overview and prognosis of the postoperative rehabilitation process

-A tour of the facility and operating room along with meeting with individuals who have already undergone such a procedure may also help to decrease patient anxiety surrounding the surgery and hospital experience.21

-Therapist must have a complete picture about the procedure, surgical approach and fused levels.

-The therapist also must know the surgical approach nd the levels fused. *clinical note: aftertion segment is fused, increased stress is placed on the levels above and below the fusion. This creates risk for acceleration of the degenerative cascade at the adjacent levels. Obviously the more levels that have been fused, the greater the stress placed on the remaining segments. When the fusion includes the L5-S1 motion segment, abnormal forces are then translated to the sacroiliac joints. To minimize these forces, the therapist must be sure that normal motion exists at all remaining segments, including the thoracic spine, shoulders, and lower extremities (LEs).

*clinical note: During a posterior fusion, the multifidi are retracted from the spine. This partially tears the dorsal divisions of the spinal nerves, resulting in partial denervation of the multifidi. If an anterior fusion also has been performed, then a midline skin incision will be apparent and the abdominal muscular incision is lateral. The incision passes through the obliques, also partially denervating them. For this reason the therapist should teach the patient the proper way to recruit the transverse abdominis (TA), multifidi, and pelvic floor muscles and watch for any substitution patterns to promote

proper spinal stabilization.

Phase I

TIME: 1 to 5 days after surgery (inpatient) and up to 6

Weeks

-Most patients are referred for physical therapy anywhere between 4 to 7 weeks after their discharge from the hospital.

GOALS: Patient education about daily movements,

abdominal stabilization, neural mobilization, and

home care principles

inpatients:

-Most patients remain in the hospital for several days after fusion surgery

-Physical therapy management during this phase consists of teaching patients the proper way to get in and out of bed, dress and perform other self-care activities, and walk (perhaps with a walker for the first 1 or 2 days).

-Strenuous abdominal stabilization exercises are not recommended at this time; however, attempts should be made to perform light TA and pelvic floor contractions to begin to practice them in different positions. The patient may use a large “sigh” or more forceful exhalation such as “blowing out a candle” to start to facilitate other abdominal muscles that

assist with bracing.

-The therapist also can teach basic and simple neural mobilization for the nerves involving the lumbosacral plexus.

-Patients and their family should leave the hospital with an understanding of the home care required until they begin their outpatient physical therapy, especially in the absence of home PT during the interim.

-Patients will be given instructions from the physician to

avoid driving, prolonged sitting, lifting, bending, and twisting.

Phase II

TIME: 6 to 10 weeks after surgery

GOALS: Increased activity, tissue remodeling, stabilization, and reconditioning

-During phase II, patients gradually increase their activity level. While taking soft tissue healing into account, the PT can safely begin to influence the direction of tissue modeling through carefully applied stress. Patients should begin to approximate normal activities while the therapist controls

-the intensity of movement and exercise. Also toward the end of this phase.

-patients should be slowly working up to 30 minutes of exercise and physical activity at least 5 days a week as recommended by the American College of Sports Medicine.23

-They can begin a light weight-training program, avoiding exercises that inappropriately load the lumbar spine but making sure to include some exercise for the lumbar paraspinals and other muscles that attach to the thoracodorsal fascia.

-Common restrictions are no lifting greater than 10╯lb

and no overhead lifting. Examples of exercises for this

phase are listed in the following sections. 

Evaluation

-assess the patient’s status and help to create an individualized program. The examination should include relevant tests and measures, such as posture, gait, range of motion (ROM), strength, balance, body mechanics, and specific functional tasks while making sure not to overload the lumbar spine. The therapist and patient can then begin to collaborate on and establish goals for treatment.

-This evaluation should include ROM for the LEs and upper extremities (UEs) but not for the lumbar spine. A complete neurologic examination should be performed to establish a baseline and should include neural tension testing.

-The therapist can perform strength testing for the Les with the exception of testing hip flexor strength.

- He or she also can check the patient’s ability to stabilize or brace the lumbar spine isometrically, which is a test of the patient’s ability to recruit the core trunk muscles to control the spine.

The goals of phase II are as follows:

• Demonstrate good body mechanics for activities of daily

living (ADL)

• Protect the surgical site from infection and mechanical

stress

• Maintain nerve root mobility at the involved levels

• Control pain and inflammation

• Minimize patient fear and apprehension

• Begin a stabilization and reconditioning program

• Improve scar and surrounding soft tissue mobility

• Treat restrictions of thoracic, UEs, and LEs that can lead

to more strain on the lumbar spine

• Education to minimize sitting time and maximize walking

time

Body Mechanics Training

The therapist should go through the entire program, which is as follows:

• In and out of bed (Fig. 16-4)

• In and out of a chair (Fig. 16-5)

• Up and down from the floor (Fig. 16-6)

• Lying postures (Fig. 16-7)

• Sitting (Fig. 16-8)

• Standing

• Dressing

• Bending (Fig. 16-9)

• Reaching

• Pushing and pulling (Fig. 16-10)

• Lifting (Fig. 16-11)

• Carrying (Fig. 16-12)

-motion if they move their hips rather than

the spine.

Instead of flexing the lumbar spine, they can “hip

hinge” (see Fig. 16-9). Rather than twist in the lumbar spine,

they can pivot on another body part (e.g., knees, elbows,

hips). When teaching a hip hinge, the PT should point out

that the hips should move back rather than down. After

surgery, patients tend to guard and move cautiously. Showing

them the way to use their momentum safely in many

Nerve Root Gliding.╇

- Patients should extend the knee while lying supine with the spine in a neutral position and the hip flexed to a 90° angle.

When tension is encountered,

-the therapist helps the patient work the knee or ankle gently back and forth, gradually increasing the ROM (Fig. 16-13).

-This stretch may cause increased symptoms during the stretch, which should resolve immediately on relaxing.

-Local inflammation occurs after lumbar spine surgery.

Because the body forms scar tissue in response to inflammation,

the nerve root can become adherent to the neural

foramen or lose elasticity. It is theorized that a nerve root

that is kept moving within its sheath cannot develop adhesions.

-the patient must keep the spine stabilized while moving the leg.

-Ultrasound should not be applied over a healing bony fusion. Patients with severe pain problems can try using a home transcutaneous electrical nerve stimulation (TENS) unit or interferential unit.

-Incisional pain can be expected to decrease gradually over 6 to 8 weeks.

The therapist should teach patients to manage flare-ups using ice, rest, and resumption of previous activities within 1 or 2 days. 

Minimizing Patient Fear and Apprehension.╇   

-Psychosocial variables have been shown to have a large influence on disability and function in individuals with chronic back pain, so ignoring these concepts could be a large detriment to the patient’s functional improvement.11

.

Stabilization, Strength, and Reconditioning.╇

• Cocontraction of the TA, multifidus, and pelvic floor muscles with and without using pressure biofeedback (BFB) (Fig. 16-14)

• Abdominal breathing

• Abdominal bracing with appropriate progression

(Fig. 16-15)

Abdominal bracing and supine marching are good exercises

to begin strengthening the trunk. Before bracing is

initiated, it is best to make sure the patient can isometrically

contract the TA, multifidi, and pelvic floor muscles.6,9,28-31

After the patient is able to do such, it is important to progress

those stabilization exercises, eventually working toward

functional goals that have been established. The patient

should be able to contract the appropriate stabilization

muscles in different postures and positions, so it is recommended

that these be practiced also in sitting, standing, and

quadruped.

In quadruped (four-point kneeling) the patient should be

able to more easily work on contracting TA while keeping

other global muscles relaxed

Adding bracing along with arm

and leg movements in this quadruped position is also a great

way to activate the multifidus and lumbar spine paraspinals

without placing the lumbar spine under undue axial load32,33

General balance activities would

also help with this type of challenge. Examples of these types

of exercises may include:

• UE or LE activities while sitting on an exercise ball (Fig.

16-17)

• Supine/hooklying activities laying vertical on a foam roll

(Fig. 16-18)

• Standing activities on a disc or rocker board

(Fig. 16-19)

• Trunk or hip perturbations in sitting or standing

(Fig. 16-20)

General strength and conditioning exercises should also

be initiated during this phase of rehabilitation after it is

cleared by the physician and the patient demonstrates appropriate

stabilization. Examples of exercises would include:

• Wall squats and sit to stand

• Half lunges

• Step ups and step downs

• Walking

• Cardiovascular reconditioning (using stair climber,

brisk walking, and pool exercises once the incision is

closed)

-Care should be taken when starting more vigorous strengthening activities, because it is recommended that the patient be able to use the appropriate stabilization muscles during components of the exercise before doing the full exercise.

Maintaining Scar and Soft Tissue Mobility.╇

-The therapist should use soft tissue techniques to maintain good scar and soft tissue mobility without disrupting the healing of these tissues (Fig. 16-21). Scar tissue tends to contract

while healing. This can create a “tight” scar that restricts

mobility.35 In cases of prolonged incisional pain it may be

beneficial to use techniques to desensitize the tissue starting

with very soft and gentle surfaces progressing to more firm

and vigorous materials.

Assessment and Treatment for Restrictions of

Thoracic, Shoulder, and Hip Mobility

The following steps will help ease restrictions of the thoracic spine and hip:

• Manual therapy for thoracic motion restrictions

• LE and UE stretches for soft tissue restrictions

• Hamstring stretches

• Hip flexor stretches (Fig. 16-22) can be initiated in later

stages with permission from the surgeon

Quadriceps stretches (begin with prone knee flexion

before progressing )

• Lumbar flexion stretch (Fig. 16-23) with surgeon approval

When initiating this stretch, the therapist must not be overly aggressive, obtaining ROM at the expense of compromising the fusion site

Up and down from the floor (Fig. 16-24)

• Hip rotator stretches (Fig. 16-25)

• Latissimus dorsi stretches (Fig. 16-26)

*One of the most stressful motions in the lumbar spine is rotation,

which causes a shearing effect across the disc. Since the

thoracic spine is designed to allow more rotation, limited

motion here may increase strain on the lumbar spine during

twisting motions. The PT can use manual mobilization techniques

to increase thoracic spine mobility

Stretching throughout phase II should be

very gentle and only pushed to the point the patient can

brace to prevent lumbar motion.

*Iliopsoas stretching is initiated in a later phase with the permission of the physician. The aggressiveness of any hip stretching is dictated by the patient’s ability to control the spine while stretching

Examples of other exercises (performed while bracing)

initiated in the later stages of phase II include the following:

• Bridging

• Heel lifts

• Superman (avoiding lumbar extension)

• Lateral pulls (light resistance with approval of surgeon)

(Fig. 16-27)

• Seated upright rowing machine

• Scapular depression (avoid resisting more than 40% of

body weight)

• Push-ups standing and leaning into the wall

• Stair climber

• Upper body ergometer (UBE)

What the therapist is attempting to

develop at this stage is not so much muscle power as kinesthetic

sense for the muscles and their role in protecting the

spine. Therefore the proper form of each exercise should be

emphasiz

Phase III

TIME: 11 to 19 weeks after surgery

GOALS: Return to work, continue to advance/progress

exercise program, practice specific skills program,

initiate resistance training program

-They often return to work with modified duties or on a part-time schedule.

At this time they should be independent with self-care duties and also with a moderately challenging home exercise program.

The use of proper mechanics should be becoming a habit but will need

to be continually reinforced during specific activities. Exercises

that address functional movement may be a great time

to reinforce those principles. More strenuous stabilization

activities, such as half and full front and side planks could

be added.

The early development of these

muscles in their role as spinal stabilizers rather than spinal

movers is a crucial component of this phase.

The previous

trunk stabilization activities should be progressed within the

patient tolerance by modifying, for example, the number of

repetitions, adding Thera-Band resistance, or performing the

exercise on a more challenging surface.

It is not advised to do complex weight lifting

tasks, but to focus on light free weight activity and machinebased

exercises that allow the patient to perform them with

proper posture, technique, and bracing. Patients with a poor

tolerance for any one position may do better on a circuittraining

program.

*Patients should be extremely careful with overhead lifting because of the axial load and compressive forces placed on the spine. -Endurance and cardiovascular exercises should also be progressed at this stage and start to progress gradually.

-For some individuals it may be advised to do more cardiovascular or resisted exercises in an aquatic rehabilitation environment

The buoyancy of the water may help to unload the spine but allow the patient to do partial weight-bearing exercises along with core and resisted extremity activity.

*At this stage the expectation is that pain continues to decrease and be at a minimal level. Those patients that continue to have an unexpected degree of pain may need to be  by the PT or by the surgeon In the absence of any physical explanation of the pain, the rehabilitation team

needs to reinforce the functional improvements and minimize

the importance of pain as a marker of improvement.

Phase IV

TIME: 20 weeks to 1 year after surgery

GOALS: Restore preinjury status, continue home

program of conditioning and stabilization

Patients should be progressing to full restoration of their preinjury

level of function and be independent with conducting their previous home and gym program.

-They should have a good grasp of not only the exercises and physical activity required to reach their goals but also ways to modify those activities, because at this stage it might be expected that the patient

may be finishing with outpatient therapy. Proper

Patients with fusions frequently develop

problems at the level above or below the fusion. For these

reasons, the patient should learn that spinal care is now

a lifetime habit and must be maintained with regular

exercise and good mechanics during all daily activities (not

just those the patient perceives as stressful).

-Patients returning to a more strenuous job or sports

are now developing the extra degree of strength and skill to do so.

- Later in this phase (and with clearance from the surgeon) they may begin agility and sport-specific drills, such as running, cutting, and jumping. If a more comprehensive weight training program is called for it should be again geared to the specific activity faced by the patient

The patient must demonstrate good trunk strength and control and good LE strength and flexibility before initiating agility drills. Although all therapists would like to relieve pain, some suffering is beyond the ability of current medical science to alleviate. This is a difficult concept for some patients to understand, and they may not be willing to accept it. Focusshould again be on improving function and less on pain abatement.

-Cognitive-behavioral interventions can continue to help with pain-related fear, social adjustments, and coping strategies that may still be difficult for patients during these later stages. Therapists should make every effort to help patients accept this reality and learn to care for themselves without seeking constant medical intervention.

reference:

1-the book

2-Burkus K, et al: Six-year outcomes of anterior lumbar interbody arthrodesis

with use of interbody fusion cages and recombinant human bone

morphogenic protein-2. J Bone Joint Surg 91:1181-1189, 2009.

Before beginning a rehabilitation program, the therapist must know whether the patient has had a fusion with or without instrumentation.

-The therapist also must know the surgical approachand the levels fused. *clinical note:After a motion segment is fused, increased stress is placed on the levels above and below thefusion. This creates risk for acceleration of the degenerative cascade at the adjacent levels. Obviously the more levels that have been fused, the greater the stress placed on the remaining segments. When the fusion includes the L5-S1 motion segment, abnormal forces are then translated to the sacroiliac joints. To minimize these forces, the therapist must be sure that normal motion exists at all remaining segments, including the thoracic spine, shoulders, and lower extremities (LEs).

*clinical note: During a posterior fusion, the multifidi are retracted from the spine. This partially tears the dorsal divisions of the spinal nerves, resulting in partial denervation of the multifidi.

5,22 If an anterior fusion also has been performed, then a midline skin incision will be apparent and the abdominal muscular incision is lateral. The incision passes through the obliques, also partially denervating them. For this reason the therapist should teach the patient the proper way to recruit the transverse abdominis (TA), multifidi, and pelvic floormuscles and watch for any substitution patterns to promote

proper spinal stabilization.

Phase I

TIME: 1 to 5 days after surgery (inpatient) and up to 6

Weeks

-Most patients are referred for physical therapy anywhere between 4 to 7 weeks after their discharge from the hospital.

GOALS: Patient education about daily movements,

abdominal stabilization, neural mobilization, and

home care principles

inpatients:

-Most patients remain in the hospital for several days after fusion surgery

-Physical therapy management during this phase consists of teaching patients the proper way to get in and out of bed, dress and perform other self-care activities, and walk (perhaps with a walker for the first 1 or 2 days).

-Strenuous abdominal stabilization exercises are not recommended at this time; however, attempts should be made to perform light TA and pelvic floor contractions to begin to practice them in different positions. The patient may use a large “sigh” or more forceful exhalation such as “blowing out a candle” to start to facilitate other abdominal muscles that

assist with bracing.

-The therapist also can teach basic and simple neural mobilization for the nerves involving the lumbosacral plexus.

-Patients and their family should leave the hospital with an understanding of the home care required until they begin their outpatient physical therapy, especially in the absence of home PT during the interim.

-Patients will be given instructions from the physician to

avoid driving, prolonged sitting, lifting, bending, and twisting.

Phase II

TIME: 6 to 10 weeks after surgery

GOALS: Increased activity, tissue remodeling, stabilization, and reconditioning

-During phase II, patients gradually increase their activity level. While taking soft tissue healing into account, the PT can safely begin to influence the direction of tissue modeling through carefully applied stress. Patients should begin to approximate normal activities while the therapist controls

-the intensity of movement and exercise. Also toward the end of this phase.

-patients should be slowly working up to 30 minutes of exercise and physical activity at least 5 days a week as recommended by the American College of Sports Medicine.23

-They can begin a light weight-training program, avoiding exercises that inappropriately load the lumbar spine but making sure to include some exercise for the lumbar paraspinals and other muscles that attach to the thoracodorsal fascia.

-Common restrictions are no lifting greater than 10╯lb

and no overhead lifting. Examples of exercises for this

phase are listed in the following sections. 

Evaluation

-assess the patient’s status and help to create an individualized program. The examination should include relevant tests and measures, such as posture, gait, range of motion (ROM), strength, balance, body mechanics, and specific functional tasks while making sure not to overload the lumbar spine. The therapist and patient can then begin to collaborate on and establish goals for treatment.

-This evaluation should include ROM for the LEs and upper extremities (UEs) but not for the lumbar spine. A complete neurologic examination should be performed to establish a baseline and should include neural tension testing.

-The therapist can perform strength testing for the Les with the exception of testing hip flexor strength.

- He or she also can check the patient’s ability to stabilize or brace the lumbar spine isometrically, which is a test of the patient’s ability to recruit the core trunk muscles to control the spine.

The goals of phase II are as follows:

• Demonstrate good body mechanics for activities of daily

living (ADL)

• Protect the surgical site from infection and mechanical

stress

• Maintain nerve root mobility at the involved levels

• Control pain and inflammation

• Minimize patient fear and apprehension

• Begin a stabilization and reconditioning program

• Improve scar and surrounding soft tissue mobility

• Treat restrictions of thoracic, UEs, and LEs that can lead

to more strain on the lumbar spine

• Education to minimize sitting time and maximize walking

time

Body Mechanics Training

The therapist should go through the entire program, which is as follows:

• In and out of bed (Fig. 16-4)

• In and out of a chair (Fig. 16-5)

• Up and down from the floor (Fig. 16-6)

• Lying postures (Fig. 16-7)

• Sitting (Fig. 16-8)

• Standing

• Dressing

• Bending (Fig. 16-9)

• Reaching

• Pushing and pulling (Fig. 16-10)

• Lifting (Fig. 16-11)

• Carrying (Fig. 16-12)

-motion if they move their hips rather than

the spine.

Instead of flexing the lumbar spine, they can “hip

hinge” (see Fig. 16-9). Rather than twist in the lumbar spine,

they can pivot on another body part (e.g., knees, elbows,

hips). When teaching a hip hinge, the PT should point out

that the hips should move back rather than down. After

surgery, patients tend to guard and move cautiously. Showing

them the way to use their momentum safely in many

Nerve Root Gliding.╇

- Patients should extend the knee while lying supine with the spine in a neutral position and the hip flexed to a 90° angle.

When tension is encountered,

-the therapist helps the patient work the knee or ankle gently back and forth, gradually increasing the ROM (Fig. 16-13).

-This stretch may cause increased symptoms during the stretch, which should resolve immediately on relaxing.

-Local inflammation occurs after lumbar spine surgery.

Because the body forms scar tissue in response to inflammation,

the nerve root can become adherent to the neural

foramen or lose elasticity. It is theorized that a nerve root

that is kept moving within its sheath cannot develop adhesions.

-the patient must keep the spine stabilized while moving the leg.

-Ultrasound should not be applied over a healing bony fusion. Patients with severe pain problems can try using a home transcutaneous electrical nerve stimulation (TENS) unit or interferential unit.

-Incisional pain can be expected to decrease gradually over 6 to 8 weeks.

The therapist should teach patients to manage flare-ups using ice, rest, and resumption of previous activities within 1 or 2 days. 

Minimizing Patient Fear and Apprehension.╇   

-Psychosocial variables have been shown to have a large influence on disability and function in individuals with chronic back pain, so ignoring these concepts could be a large detriment to the patient’s functional improvement.11

.

Stabilization, Strength, and Reconditioning.╇

• Cocontraction of the TA, multifidus, and pelvic floor muscles with and without using pressure biofeedback (BFB) (Fig. 16-14)

• Abdominal breathing

• Abdominal bracing with appropriate progression

(Fig. 16-15)

Abdominal bracing and supine marching are good exercises

to begin strengthening the trunk. Before bracing is

initiated, it is best to make sure the patient can isometrically

contract the TA, multifidi, and pelvic floor muscles.6,9,28-31

After the patient is able to do such, it is important to progress

those stabilization exercises, eventually working toward

functional goals that have been established. The patient

should be able to contract the appropriate stabilization

muscles in different postures and positions, so it is recommended

that these be practiced also in sitting, standing, and

quadruped.

In quadruped (four-point kneeling) the patient should be

able to more easily work on contracting TA while keeping

other global muscles relaxed

Adding bracing along with arm

and leg movements in this quadruped position is also a great

way to activate the multifidus and lumbar spine paraspinals

without placing the lumbar spine under undue axial load32,33

General balance activities would

also help with this type of challenge. Examples of these types

of exercises may include:

• UE or LE activities while sitting on an exercise ball (Fig.

16-17)

• Supine/hooklying activities laying vertical on a foam roll

(Fig. 16-18)

• Standing activities on a disc or rocker board

(Fig. 16-19)

• Trunk or hip perturbations in sitting or standing

(Fig. 16-20)

General strength and conditioning exercises should also

be initiated during this phase of rehabilitation after it is

cleared by the physician and the patient demonstrates appropriate

stabilization. Examples of exercises would include:

• Wall squats and sit to stand

• Half lunges

• Step ups and step downs

• Walking

• Cardiovascular reconditioning (using stair climber,

brisk walking, and pool exercises once the incision is

closed)

-Care should be taken when starting more vigorous strengthening activities, because it is recommended that the patient be able to use the appropriate stabilization muscles during components of the exercise before doing the full exercise.

Maintaining Scar and Soft Tissue Mobility.╇

-The therapist should use soft tissue techniques to maintain good scar and soft tissue mobility without disrupting the healing of these tissues (Fig. 16-21). Scar tissue tends to contract

while healing. This can create a “tight” scar that restricts

mobility.35 In cases of prolonged incisional pain it may be

beneficial to use techniques to desensitize the tissue starting

with very soft and gentle surfaces progressing to more firm

and vigorous materials.

Assessment and Treatment for Restrictions of

Thoracic, Shoulder, and Hip Mobility

The following steps will help ease restrictions of the thoracic spine and hip:

• Manual therapy for thoracic motion restrictions

• LE and UE stretches for soft tissue restrictions

• Hamstring stretches

• Hip flexor stretches (Fig. 16-22) can be initiated in later

stages with permission from the surgeon

Quadriceps stretches (begin with prone knee flexion

before progressing )

• Lumbar flexion stretch (Fig. 16-23) with surgeon approval

When initiating this stretch, the therapist must not be overly aggressive, obtaining ROM at the expense of compromising the fusion site

Up and down from the floor (Fig. 16-24)

• Hip rotator stretches (Fig. 16-25)

• Latissimus dorsi stretches (Fig. 16-26)

*One of the most stressful motions in the lumbar spine is rotation,

which causes a shearing effect across the disc. Since the

thoracic spine is designed to allow more rotation, limited

motion here may increase strain on the lumbar spine during

twisting motions. The PT can use manual mobilization techniques

to increase thoracic spine mobility

Stretching throughout phase II should be

very gentle and only pushed to the point the patient can

brace to prevent lumbar motion.

*Iliopsoas stretching is initiated in a later phase with the permission of the physician. The aggressiveness of any hip stretching is dictated by the patient’s ability to control the spine while stretching

Examples of other exercises (performed while bracing)

initiated in the later stages of phase II include the following:

• Bridging

• Heel lifts

• Superman (avoiding lumbar extension)

• Lateral pulls (light resistance with approval of surgeon)

(Fig. 16-27)

• Seated upright rowing machine

• Scapular depression (avoid resisting more than 40% of

body weight)

• Push-ups standing and leaning into the wall

• Stair climber

• Upper body ergometer (UBE)

What the therapist is attempting to

develop at this stage is not so much muscle power as kinesthetic

sense for the muscles and their role in protecting the

spine. Therefore the proper form of each exercise should be

emphasiz

Phase III

TIME: 11 to 19 weeks after surgery

GOALS: Return to work, continue to advance/progress

exercise program, practice specific skills program,

initiate resistance training program

-They often return to work with modified duties or on a part-time schedule.

At this time they should be independent with self-care duties and also with a moderately challenging home exercise program.

The use of proper mechanics should be becoming a habit but will need

to be continually reinforced during specific activities. Exercises

that address functional movement may be a great time

to reinforce those principles. More strenuous stabilization

activities, such as half and full front and side planks could

be added.

The early development of these

muscles in their role as spinal stabilizers rather than spinal

movers is a crucial component of this phase.

The previous

trunk stabilization activities should be progressed within the

patient tolerance by modifying, for example, the number of

repetitions, adding Thera-Band resistance, or performing the

exercise on a more challenging surface.

It is not advised to do complex weight lifting

tasks, but to focus on light free weight activity and machinebased

exercises that allow the patient to perform them with

proper posture, technique, and bracing. Patients with a poor

tolerance for any one position may do better on a circuittraining

program.

*Patients should be extremely careful with overhead lifting because of the axial load and compressive forces placed on the spine. -Endurance and cardiovascular exercises should also be progressed at this stage and start to progress gradually.

-For some individuals it may be advised to do more cardiovascular or resisted exercises in an aquatic rehabilitation environment

The buoyancy of the water may help to unload the spine but allow the patient to do partial weight-bearing exercises along with core and resisted extremity activity.

*At this stage the expectation is that pain continues to decrease and be at a minimal level. Those patients that continue to have an unexpected degree of pain may need to be  by the PT or by the surgeon In the absence of any physical explanation of the pain, the rehabilitation team

needs to reinforce the functional improvements and minimize

the importance of pain as a marker of improvement.

Phase IV

TIME: 20 weeks to 1 year after surgery

GOALS: Restore preinjury status, continue home

program of conditioning and stabilization

Patients should be progressing to full restoration of their preinjury

level of function and be independent with conducting their previous home and gym program.

-They should have a good grasp of not only the exercises and physical activity required to reach their goals but also ways to modify those activities, because at this stage it might be expected that the patient

may be finishing with outpatient therapy. Proper

Patients with fusions frequently develop

problems at the level above or below the fusion. For these

reasons, the patient should learn that spinal care is now

a lifetime habit and must be maintained with regular

exercise and good mechanics during all daily activities (not

just those the patient perceives as stressful).

-Patients returning to a more strenuous job or sports

are now developing the extra degree of strength and skill to do so.

- Later in this phase (and with clearance from the surgeon) they may begin agility and sport-specific drills, such as running, cutting, and jumping. If a more comprehensive weight training program is called for it should be again geared to the specific activity faced by the patient

The patient must demonstrate good trunk strength and control and good LE strength and flexibility before initiating agility drills. Although all therapists would like to relieve pain, some suffering is beyond the ability of current medical science to alleviate. This is a difficult concept for some patients to understand, and they may not be willing to accept it. Focusshould again be on improving function and less on pain abatement.

-Cognitive-behavioral interventions can continue to help with pain-related fear, social adjustments, and coping strategies that may still be difficult for patients during these later stages. Therapists should make every effort to help patients accept this reality and learn to care for themselves without seeking constant medical intervention.

reference:

1-the book

2-Burkus K, et al: Six-year outcomes of anterior lumbar interbody arthrodesis

with use of interbody fusion cages and recombinant human bone

morphogenic protein-2. J Bone Joint Surg 91:1181-1189, 2009.