Finally, the home exercise program must be customized in conjunction with the surgeon, based on the surgical procedure, the associated contraindications, and the current func-tional sta
Trang 1Table 5 (Cont.)
Getting
dressed
To instruct the patient about
getting dressed with minimal
loading of the spine
Sitting To inform the patient about the
optimal sitting posture and
duration If necessary, a
sup-portive pillow is recommended
Driving To instruct a patient on how to
get in and out of a car The
position of the seat should be
discussed as well as the
impor-tance of short breaks when
driving over a longer period of
time
Taking a
shower or
bath
To evaluate self-care at home
patient’s daily routine To ensure good compliance and motivation, it is of great
importance that the exercises are simple and of short duration Finally, the home
exercise program must be customized in conjunction with the surgeon, based on
the surgical procedure, the associated contraindications, and the current
func-tional status of the patient (Tables 6, 7).
Trang 2Table 6 Home exercise program after lumbar surgery
Activation of
m transversus
abdominis
To increase the ability of selective transverse abdo-minis activation
Coordination of
m transversus
abdominis while
moving the
lower extremity
To increase independency between active lumbar spine stabilization and movement of the extrem-ity
Stabilization
of the trunk
muscles and
strengthening
of the lower
extremity
muscles
Exercise with regard to activities of daily living (sit
to stand) and body aware-ness
Stretching of the
gluteal muscles
To increase flexibility of the gluteal muscles and gentle mobilization of the lower lumbar spine into flexion
However, the therapist may provide patients with educational information regarding back care, basic body mechanics and practical tips for self-care This can be in the form of group education, brochures and accurate internet web sites.
After soft tissue healing,
stretching and strengthening exercises
can be intensified
Approximately 3 months after surgery, biological healing is complete and exercises can be progressed as tolerated by the patient and according to the sur-geon’s protocol Stretching and strengthening exercises can be intensified and should be performed two to three times a week [23] In addition, it has been shown that an aerobic exercise program can be beneficial for successful rehabili-tation [3].
Depending on the intervention and pain tolerance, the patient should be as active and independent as possible, returning to most of their daily activities.
If the postoperative reassessment by the surgeon at 4 – 6 weeks postoperatively reveals any difficulties or irregularities, the patient is referred to physical ther-apy Depending on the patient’s presentation, the physical therapist will provide
an individual treatment and management plan aiming to restore normal
Trang 3func-Table 7 Home exercise program after cervical surgery
Exercise Goal
Activation
of the deep
neck flexors
To increase the
abil-ity of selective deep
neck flexor activation
Stabilization
of the cervical
spine
To facilitate body
awareness and
improve cervical
posture
Stabilization
of the cervical
spine during
movement
To facilitate optimal
cervical posture in
activities of daily
living (sit to stand)
tion, activity and participation The intervention is planned with regard for the
surgical procedure and is based on:
) loading disorder: symptoms in sustained positions
) movement disorder
) motor control disorder
If the patient’s complaints are of a loading disorder, the treatment of choice would
be mobilization of possible hypomobile segments in order to restore optimal
posture Moreover, advice on posture, strengthening of impaired muscles and
pain-relieving positions and ergonomics is given to the patient.
In case of a rehabilitation deficit, individual treatment and management is provided after 4 – 6 weeks
Treatment of a movement disorder focuses on improving hypomobile
move-ment segmove-ments and restoring optimal muscle extensibility Stabilizing exercises
with individual focus on the impaired muscle function and postural advice are
the main management strategies for a motor control disorder.
Trang 4The aim of aftercare is to
maximize the individual’s
resumption of all ADL
The aftercare period starts at around 3 months after surgery, when biological healing is complete and exercises can be progressed as tolerated by the patient and depending on the intervention The aim of aftercare is to maximize the indi-vidual’s resumption of all functional activities of daily living including personal, social, and occupational domains The rehabilitation program should follow the current guidelines of back and neck pain management in which physical, thera-peutic, and recreational exercises are recommended [1] The continuation of a back- or neck-related home exercise program should be encouraged, with an
emphasis on neck and trunk flexibility and strength Aerobic conditioning
should also be encouraged as the benefits to the entire body are evident [1] Extensive evidence exists legitimizing the need for activity as compared to rest, although to date it remains unclear whether any specific type of exercise is more effective than any other [31].
Physical Rehabilitation Training
If a patient still has deficits in function, activity or participation at 3 months post-operatively, a physical rehabilitation program can be started This rehabilitation program should be performed two to three times a week and continuously inten-sified [23] In addition, it has been shown that an aerobic exercise program can
be beneficial for successful rehabilitation [3] Rehabilitation after spinal surgery
will be based on the PRT system (physical rehabilitation training) [32] Upon the
first appointment, the patient’s need for their ADL and their loading ability will
be analyzed in order to compose an individual program to eliminate the remain-ing dysfunctions specifically.
The standard program progresses according to the following stages:
) proprioception ) strength endurance ) acceleration/deceleration training
Physical rehabilitation
consists of coordination,
strength endurance and
acceleration/deceleration
training
Proprioception is trained first in a motor learning approach to improve muscle
coordination This stage of the training will last 3 – 6 weeks on average and is underloaded, which means the patient can perform the training without fatigue
in the target muscles The strength endurance stage is then reached and the
patient will progress until they can perform 8 – 14 repetitions under load while provoking fatigue in the target muscles Once the patient can perform the exer-cises with the required weight for two to three consecutive trainings, the program
is progressed to the next stage Acceleration and deceleration training, which
differ from strength endurance training in the rhythm of the performance, is the next stage of the training The same exercises are implemented at an increased speed than before This promotes further adaptation and remodeling of the con-nective tissues.
Return to Work
The return to work is not closely correlated with the extent of the intervention.
On the contrary, confounding factors seem to play an even more important role [9, 26] The rate of resumption of heavy work is difficult to determine and will be
Return to work is key in
postoperative rehabilitation
dictated by the surgeon with consideration of the operative procedure and the degree of postoperative soft tissue and bony alterations This decision will often
be anecdotal and will vary from surgeon to surgeon We recommend that the patient resumes work as soon as possible.
Trang 5Table 8 Home exercise program after lumbar surgery
Exercise Goal
Dead lift To stabilize the trunk
during bending
activi-ties
Progression: dead lift in
extension
Front press To stabilize the trunk
during upper extremity
movements
Bent over
barbell row
To stabilize the trunk in
an inclined position
Trang 6Table 8 (Cont.)
Exercise Goal
Bent over barbell row
Progression: bent over dumbbell rotation
Barbell rotation
To stabilize the trunk during rotational activi-ties
Recreational Activities
Activity resumption should
be as soon as possible
Most studies investigating return to sports and recreational activities were
per-formed on athletes [7, 36, 40] It has been found that different factors may influ-ence the time to return to recreational activities Among them are the patient’s preoperative health condition, age, and quality of surgery It is suggested that patient motivation influences recovery from spinal surgery and return to recrea-tional activities [36] Limited data assist with decision-making for return to sport after (thoraco-) lumbar fusion [40] Some of the criteria used to determine return
to play included a solid fusion based on clinical assessment and imaging studies and full recovery as determined by near normal range of motion and normal muscular strength Return to sport decisions must be made on an individual basis, and various factors, such as the number of levels fused, must be taken into account.
Obstacles for Rehabilitation Morphological Obstacles and General Medical Obstacles
Care must be taken to distinguish between procedure-specific morphological obstacles and general medical obstacles Morphological obstacles for rehabilita-tion can occur immediately postoperatively or after a latency of a few days It is important to emphasize the difference between persistent and new symptoms Possible immediate postoperative complications include:
) neural injury (de novo) ) neural compression (persistent or de novo, e.g., epidural bleeding) ) early infection
Trang 7Late postoperative morphological obstacles for rehabilitation include:
) non-union
) late infection
) persistent neurological dysfunction
) instability (de novo or persistent)
) medical complications (e.g., myocardial infarction, stroke, pulmonary
embolus)
) other comorbidities
Comorbidities are frequent obstacles for recovery
During the physical assessment a patient’s medical history is critical in order to
identify comorbidities such as hypertension, diabetes mellitus, and pulmonary
and cardiovascular diseases These comorbidities have been linked to the need
for postoperative critical care and increased hospitalization [15].
Psychosocial Obstacles
Psychosocial obstacles for rehabilitation include:
) psychosocial factors (psychological, behavioral, social factors) [35] (see
Chapter 11 )
) fear-avoidance behavior [34]
) kinesiophobia [18]
A clinical assessment of risk factors for delayed recovery is required and must
include attention to psychosocial factors (Chapter 21 ) The fear avoidance
model describes how patients avoid normal activities if they believe these
activi-ties will provoke pain Fear of movement or (re)injury, also called kinesiophobia,
is associated with avoidance behaviors that increase functional disability in
chronic low back pain Kinesiophobia is an excessive, irrational and debilitating
fear of physical movement and activity resulting from a feeling of vulnerability to
painful injury or reinjury [33] Treatment to reduce this fear must include
cogni-tive behavioral techniques that address the perceived threat of movement or
pain, in conjunction with progressive exercise and function.
Work-Related Obstacles
As outlined in Chapter 21 , job satisfaction has been associated with low back
pain disability Similarly, psychological aspects of work such as:
) occupational mental stress
) general job satisfaction
) job related resignation
were shown to be related to postoperative relief of disability [26].
Recapitulation
Epidemiology. The literature is sparse on
postoper-ative rehabilitation after spinal surgery This lack of
evidence includes not only the epidemiology but
also the efficacy of postoperative rehabilitation
af-ter spinal surgery.
Conceptional background. Ideally, the
rehabilita-tion process is initiated prior to surgery through a
precise and thorough preoperative assessment.
Initially an accurate diagnosis is imperative so that the physician can identify an optimal surgical inter-vention A thorough physical examination and
medical history is useful for identifying comorbidi-ties, since these have the potential to impede the
rate of postoperative rehabilitation The patient’s
functional status must also be carefully scrutinized.
Trang 8An international classification system, ICF, has been
established for determining the impact of a
condi-tion or illness with regard to human funccondi-tioning
and its restrictions This system takes into account
function and disability (impairment) with
consider-ation of contextual factors (participconsider-ation in the
activities of daily living, and work and leisure
pur-suits) Based on the physical and functional
assess-ments, postoperative rehabilitation plans are
initi-ated The physician and patient must have an
unambiguous understanding of the other’s
expec-tations and the role of each of them in the
postop-erative recovery After surgery, an ongoing
reas-sessment of the patient’s status is indicated and the
rehabilitation plans are modified accordingly.
Principles of postoperative rehabilitation. The
postoperative period can be divided into three
phases: Immediate aftercare, rehabilitation and
aftercare Immediate aftercare begins with an
evalu-ation by the therapist to determine the individual’s
current physical capacity and to anticipate special
needs Pain management must be carefully
ad-dressed as preoperative pain is often the driving
fac-tor leading to surgery and can impede the patient’s
performance due to the physical and psychological implications Treatment will include transfer and gait training, exercise instruction and education on basic back care This will continue throughout the inpa-tient period or until independence is achieved.
The rehabilitation phase continues until 6 months
postoperatively During this phase patients gradu-ally increase their activities of daily living, the home exercise program continues and all progresses under the guidance of the treating physician Any inconsistencies between function and physical
sta-tus must be addressed During the aftercare phase,
patients are expected to progress further in their functional level both personally and within the occu-pational and social spheres Continued exercise is encouraged, both low back stretching and strength-ening as well as general aerobic conditioning.
To date the existing scientific literature supports exercise after spinal surgery, although no particular form of exercise has been proven optimal Little exists in the literature describing the ideal postop-erative rehabilitation protocol, and common clini-cal practice is the point of reference All involved in spinal surgery rehabilitation must strive to fill these voids.
Key Articles
WHO ( 2001) International Classification of Functioning, Disability and Health ICF, Geneva
The International Classification of Functioning, Disability and Health was published by the World Health Organization It describes situations with regard to human functioning and its restrictions from a biological, individual and social perspective
Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M ( 2003) Rehabil-itation following first-time lumbar disc surgery: a systematic review within the frame-work of the Cochrane collaboration Spine 28:209–218
Systematic review of randomized controlled trials about rehabilitation following first-time lumbar disc surgery No evidence exists for restriction of activity after lumbar sur-gery Strong evidence is found for intensive exercise programs
Manniche C, Skall HF, Braendholt L, Christensen BH, Christophersen L, Ellegaard B, Heilbuth A, Ingerslev M, Jorgensen OE, Larsen E ( 1993) Clinical trial of postoperative dynamic back exercises after first lumbar discectomy Spine 18:92–97
Randomized controlled trial investigating a high intensity compared to a mild physical rehabilitation program after discectomy An intensive exercise program appears to increase patient behavioural support and results in work capacity improvements and patient self-rated disability levels
Kjellby-Wendt G, Styf J ( 1998) Early active training after lumbar discectomy A prospec-tive, randomized, and controlled study Acta Orthop Scand Suppl 23:2345–2351
A randomized controlled trial demonstrating the advantages of an early active treatment program beginning immediately after lumbar discectomy compared to a less active pro-gram
Trang 91 Abenhaim L, Rossignol M, Valat JP, Nordin M, Avouac B, Blotman F, Charlot J, Dreiser RL,
Legrand E, Rozenberg S, Vautravers P (2000) The role of activity in the therapeutic
manage-ment of back pain Report of the International Paris Task Force on Back Pain Spine 25:1S–
33S
2 Alaranta H, Hurme M, Einola S, Kallio V, Knuts LR, Torma T (1986) Rehabilitation after
sur-gery for lumbar disc herniation: results of a randomized clinical trial Int J Rehabil Res
9:247 – 257
3 Brennan GP, Shultz BB, Hood RS, Zahniser JC, Johnson SC, Gerber AH (1994) The effects of
aerobic exercise after lumbar microdiscectomy Spine 19:735 – 739
4 Burke SA, Harms-Constas CK, Aden PS (1994) Return to work/work retention outcomes of
a functional restoration program A multi-center, prospective study with a comparison
group Spine 19:1880 – 1885
5 Carragee EJ, Helms E, O’Sullivan GS (1996) Are postoperative activity restrictions necessary
after posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases
Spine 21:1893 – 1897
6 Danielsen JM, Johnsen R, Kibsgaard SK, Hellevik E (2000) Early aggressive exercise for
post-operative rehabilitation after discectomy Spine 25:1015 – 1020
7 Debnath UK, Freeman BJ, Gregory P, de la Harpe D, Kerslake RW, Webb JK (2003) Clinical
outcome and return to sport after the surgical treatment of spondylolysis in young athletes
J Bone Joint Surg Br 85:244 – 249
8 Dolan P, Greenfield K, Nelson RJ, Nelson IW (2000) Can exercise therapy improve the
out-come of microdiscectomy? Spine 25:1523 – 1532
9 Donceel P, Du BM (1998) Fitness for work after surgery for lumbar disc herniation: a
retro-spective study Eur Spine J 7:29 – 35
10 Donceel P, Du BM, Lahaye D (1999) Return to work after surgery for lumbar disc herniation
A rehabilitation-oriented approach in insurance medicine Spine 24:872 – 876
11 Gejo R, Kawaguchi Y, Kondoh T, Tabuchi E, Matsui H, Torii K, Ono T, Kimura T (2000)
Mag-netic resonance imaging and histologic evidence of postoperative back muscle injury in
rats Spine 25:941 – 946
12 Gejo R, Matsui H, Kawaguchi Y, Ishihara H, Tsuji H (1999) Serial changes in trunk muscle
performance after posterior lumbar surgery Spine 24:1023 – 1028
13 Greenough CG, Peterson MD, Hadlow S, Fraser RD (1998) Instrumented posterolateral
lum-bar fusion Results and comparison with anterior interbody fusion Spine 23:479 – 486
14 Hagg O, Fritzell P, Ekselius L, Nordwall A (2003) Predictors of outcome in fusion surgery for
chronic low back pain A report from the Swedish Lumbar Spine Study Eur Spine J 12:22 – 33
15 Harris OA, Runnels JB, Matz PG (2001) Clinical factors associated with unexpected critical
care management and prolonged hospitalization after elective cervical spine surgery
Criti-cal Care Medicine 29:1898 – 1902
16 Johnson EW, Burkhart JA, Earl WC (1972) Electromyography in postlaminectomy patients
Archiv Phys Med Rehabil 53:407 – 409
17 Kjellby-Wendt G, Styf J (1998) Early active training after lumbar discectomy A prospective,
randomized, and controlled study Acta Orthopaedica Scandinavica Suppl 23:2345 – 2351
18 Kori SH, Miller RP, Todd DD (1990) Kinesiophobia: a new view of chronic pain behaviour
Pain Management 3:35 – 43
19 Mahomed NN, Liang MH, Cook EF, Daltroy LH, Fortin PR, Fossel AH, Katz JN (2002) The
importance of patient expectations in predicting functional outcomes after total joint
art-hroplasty J Rheumatol 29:1273 – 1279
20 Manniche C, Asmussen K, Lauritsen B, Vinterberg H, Karbo H, Abildstrup S,
Fischer-Niel-sen K, Krebs R, IbFischer-Niel-sen K (1993) Intensive dynamic back exercises with or without
hyperex-tension in chronic back pain after surgery for lumbar disc protrusion A clinical trial Spine
18:560 – 567
21 Manniche C, Skall HF, Braendholt L, Christensen BH, Christophersen L, Ellegaard B,
Heil-buth A, Ingerslev M, Jorgensen OE, Larsen E (1993) Clinical trial of postoperative dynamic
back exercises after first lumbar discectomy Spine 18:92 – 97
22 Mayer TG, Kondraske G, Mooney V, Carmichael TW, Butsch R (1989) Lumbar myoelectric
spectral analysis for endurance assessment A comparison of normals with deconditioned
patients Spine 14:986 – 991
23 Medicine ACoS (1991) Guidelines for Exercise Testing and Prescription Lea & Febiger,
Phil-adelphia
24 Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M (2003)
Rehabilita-tion following first-time lumbar disc surgery: a systematic review within the framework of
the Cochrane collaboration Spine 28:209 – 218
25 Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder MW (2002)
Rehabili-tation after lumbar disc surgery Cochrane Database Syst Rev: CD003007
Trang 1026 Schade V, Semmer N, Main CJ, Hora J, Boos N (1999) The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy Pain 80:
239 – 249
27 Stambough JL (2001) Matching patient and physician expectations in spine surgery leads to improved outcomes Spine J 1:234
28 Stucki G, Ewert T, Cieza A (2003) Value and application of the ICF in rehabilitation medi-cine Disabil Rehabil 25:628 – 634
29 Stucki G, Sangha O (1997) Principles of rehabilitation In: Klippel JH, Dieppe PA (eds) Rheu-matology Mosby, London
30 Taylor VM, Deyo RA, Ciol M, Farrar EL, Lawrence MS, Shonnard NH, Leek KM, McNeney
B, Goldberg HI (2000) Patient-oriented outcomes from low back surgery: a community-based study Spine 25:2445 – 2452
31 van Tulder MW, Malmivaara A, Esmail R, Koes BW (2000) Exercise therapy for low back pain Cochrane Database Syst Rev:CD000335
32 Van Wingerden BAM (1995) Connective tissue in rehabilitation Scipro Verlag, Vaduz
33 Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H (1995) Fear of movement/(re)injury
in chronic low back pain and its relation to behavioral performance Pain 62:363 – 372
34 Waddell G (2004) Beliefs about back pain In: Back pain revolution Churchill Livingstone, Edinburgh, pp 221 – 240
35 Waddell G, Bircher M, Finlayson D, Main CJ (1984) Symptoms and signs: physical disease or illness behaviour? British Medical Journal (Clinical Research Edition) 289:739 – 741
36 Watkins RGt, Williams LA, Watkins RG, 3rd (2003) Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes Spine J 3:100 – 105
37 Weber BR, Grob D, Dvorak J, Muntener M (1997) Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle Spine 22:1765 – 1772
38 WHO (1980) ICIDH International Classification of Impairments, Disabilities and Handi-caps WHO, Geneva
39 WHO (2001) International Classification of Functioning, Disability and Health: ICF WHO, Geneva
40 Wright A, Ferree B, Tromanhauser S (1993) Spinal fusion in the athlete Clinics Sports Medi-cine 12:599 – 602