Lumbar Fusion

Post Operative Spine RehabLumbar Fusion Treatment Guideline

Precautions

• Promote AROM after 8-10 weeks
• Avoid all exercises that reproduce or increase the pain

Phase I: Immediate post Surgical Phase (IPSP) 08 weeks

Goals:

1. Decrease pain and inflammation.
2. Increase activity toleranc
3. Encourage wound healing.
4. Increase aerobic tolerance (independent with home program 20 min tolerance to exercise).
5. Monitor for signs of possible infection.
6. Educate on body mechanics and posture for bed mobility

Precautions:

1. Prevent excessive initial mobility or stress on tissues
2. Avoid lifting, twisting, or bending of the lumbar spine for 6 weeks

Treatment Summary:

1. Education on bed mobility and transfers with proper spine positioning.
2. Reinforce basic postop home exercise program including
   1. Ankle pumps
   2. Long arc and short arc quadriceps
   3. Diaphragmatic breathing
   4. Relaxation exercises
   5. Abdominal isometric exercises
3. 3. Increase tolerance to walking to ½ mile daily (1530 min cardiovascular activity)
4. Reinforce sitting, standing and ADL modifications with neutral spine and proper body mechanics.

Criteria for progression:

1. Pain and swelling within toleranc
2. Independent HEP
3. Tolerance of 15 min of exercise and 1530 min of cardiovascular exercis
4. Functional ADL for self care/hygiene

Phase II: Initiation of OPPT 812 weeks/23 times per week

Goals:

1. Patient education/Back school
2. Reestablish neuromuscular recruitment of the multifidus (Functional dynamic lumbar stability)
3. Normalization of flexibility deficits in extremities
4. Normalization of any gait deviations
5. Return to activities of daily living
6. Improve positional tolerances for return to work

Precautions:

1. Avoid lumbar loading
2. Avoid twisting and bending of the lumbar spin
3. Limit lumbar extension
4. No standing ROM testing till 12 weeks

Treatment Summary:

• Back Education Program
  • Anatomy, Pathology, & Biomechanics
  • Reinforce neutral spine positioning
  • Body mechanics and training: Performance of functional activities with neutral spine and
    protective positions
• Manual Therapy:
  • Grade 1 or grade 2 joint mobs for neuromodulation of pain
  • Scar tissue mobilization. Educate patient on self mobilization of scar.
  • Soft tissue mobilization of soft tissue restrictions.
• Exercises:
  • Train Neutral lumbar position: Create independent movement of the pelvis and then find and
    maintain a neutral position of the lumbar spin
  • Diaphragmatic breathing: Proper breathing technique without the use of accessory respiratory
    muscles.
  • Pelvic stabilization exercises with emphasis on transverse abdominals and multifidus
  • Unloaded Pelvic and Lumbar ROM (supported): Pelvic rocks, Wig wags, Pelvic clocks. All
    performed in neutral and protective positions
  • Hip and knee flexibility exercises: Decreases stress on lumbar spine and makes it easier to
    maintain neutral spin (hamstrings, piriformis, gluteal, quads, hip flexors, gastroc, soleus etc)
  • Initiate acquatics (if available and indicated)
  • Cardiovascular training, treadmill, UBE, stationary bike (patient must have good pelvic
    control)
  • Initiate balance exercises (week 1012)
  • Address other mechanical restrictions as needed
  • Modalities for symptom modulation if needed

Criteria for progression:

1. Patient has working knowledge of body and lifting mechanics.
2. Able to hold cocontraction of multifidus/transverse abdominals for 0 sec
3. Cardiovascular tolerance to 30 min/day
4. Dynamic sitting and standing tolerance of 1560 min

Phase III: Advanced PT 1218 weeks/23 times per week.

Goals:

1. Progress with strengthening and flexibility exercises.
2. Initiate lifting and posture training
3. Progress stabilization and trunk control

Treatment Summary:

• Manual Therapy:
  • Joint mobilization of adjacent restrictions of thoracic spine, hip/pelvis.
  • Soft tissue mobilization of soft tissue restrictions.
• Exercises:
  • Continue with ROM exercises for lumbar spin
  • Advanced balance exercises
  • Neural mobilization exercises.
  • Advanced stabilization and proprioceptive training, Multiplane stabilization/mobility
  • Advanced Hip/Core strengthening exercises: Functional exercises like chops/diagonal lifts,
    squatting, lunging
  • Lifting training with proper postur (floor to waist and waist to shoulder level)
  • Body mechanics drills
  • FCE if appropriate

Criteria for discharge:

1. Manual muscle testing is within functional limits
2. Independent with gym program
3. Trunk ROM within functional limits

Pearls of rehab:

• Focus on local muscle systems (tonic/postural/stabilizing) lumbar multifidus, internal oblique,
  transverse abdominals, psoas major, quadratus lumborum, lumbar portion of lumbar iliocostalis
  lumborum before global (phasic/primary movers) such as rectus abdominals, external oblique,
  and portion of iliocostalis lumborum. Local muscles are shorter in length and closer to axis or
  rotation while the global muscles have no direct attachment on the spin
• Avoid preloading the spine in posterior pelvic tilt.
• Avoid prone upper body extensions, or prone leg extensions to avoid high compressive load of the already weakened spine)
• Nopain no gain axiom usually does not apply to the spine
• Because of diurnal variations in fluid level of the intervertebral disks (more hydrated early
  morning) it would be unwise to perform full range spinal motions (bending) shortly after rising
  from the bed
• Focus on low load high repetitions to improve endurance rather than high load low repetition for strength.
• There is some evidence that low back exercises are most beneficial when performed daily.
• Focus on pain relief with Oswestry scores of 4060, with scores of 2040 focus on decreasing
  pain, muscle reeducation, gradual strengthening, flexibility and improve cardiovascular
  endurance, with scores less than 20 focus on work simulation and progressive strengthening.