Lumbar Spine Management

Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education

Are we being billed for this?Are we being billed for this?

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Objectives

Discuss the components of the ICF l ifi ti hclassification scheme

Describe the treatment interventions used for th i t fthe primary management of:– Pain

Stiffness– Stiffness– Weakness

Describe treatment considerations for Describe treatment considerations for rehabilitation after disc or fusion surgery

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TREATMENT BY CLASSIFICATION

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“Old” Classification Categories

Treatment-based classification (TBC)classification (TBC) system (Delitto et al 1995))– Pain-dominant treatment

Specific Exercise Traction Traction

– Impairment-dominant treatment

M bili ti Mobilization Stabilization

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“New” Classification Categories

ICF-based system (Delitto et al, JOSPT 2012)– Pain-dominant treatment

Acute LBP with referred LE pain Acute - Chronic LBP with radiating LE pain

– Impairment-dominant treatment Acute - Chronic LBP with mobility deficits Acute - Chronic LBP with movement impairments Acute Chronic LBP with movement impairments Acute LBP with related cognitive or affective tendencies Chronic LBP with related generalized pain

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Acute LBP with Referred LE Pain

Often worsens with flexion and sitting

Preference for lateral shift – Visible frontal plane and sitting

Centralization with specific postures/ROM

Limited lumbar extension

deviation of shoulders to pelvis

Preference for extensionSymptoms distal to the Limited lumbar extension

mobility Lateral trunk shift possible

Fi di f

– Symptoms distal to the buttock

– Symptoms centralize with lumbar extension

Findings of subacute/chronic LBP with movement impairments

Delitto et al JOSPT 2012

– Symptoms peripheralizewith lumbar flexion

Preference for tractionNo movements centralize– Delitto et al, JOSPT 2012 – No movements centralize symptoms

Fritz et al 20076

Acute-Chronic LBP with Radiating Pain

LE paresthesias, numbness weakness

Preference for flexionAge > 50numbness, weakness,

DTR changes possible Concordant sx with initial

– Age > 50– Imaging evidence of lumbar

spinal stenosis Preference for traction

to mid range (acute), mid to end range (subacute), or sustained mvts/ nerve

Preference for traction– Signs and symptoms of

nerve root compression

Fritz et al 2007or sustained mvts/ nerve tension tests

Delitto et al, JOSPT 2012

Fritz et al 2007

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Acute-Chronic LBP with Mobility Deficits

Restricted ROM/segmental mobility

Manipulation CPR Asymmetrical lateralROM/segmental mobility

of at least one of the following regions:

Asymmetrical lateral flexion

Positive Cibulka clusterFritz et al 2007

– Thoracic– Lumbar– Lumbopelvic

Fritz et al 2007

Lumbopelvic – Hip

Concordant sx with LS PA ( t ) dPA (acute) or end range movements (subacute)

Delitto et al, JOSPT 20128

Acute-Chronic LBP with Movement Impairments

Recurrent LBP, commonly referred

Stabilization CPR Recurrent episodes with trivial referred

Concordant sx with LS PA (acute-subacute), initial to mid range mvts (acute), mid to

ponset

History of lateral shift with alternating sides

Prior use of manipulation forrange mvts (acute), mid to end range mvts (subacute), or sustained end range mvts (chronic)

Prior use of manipulation for relief

Trauma, pregnancy Relief with bracing( )

Hypermobile PA Stiff Thorax, Pelvis, Hips Weak Trunk Hips

gFritz et al 2007

Weak Trunk, HipsDelitto et al, JOSPT 2012

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Acute LBP with Related Cognitive or Affective TendenciesChronic LBP with Related Generalized Pain

One or more of the following:

– “During the past month, have you often beenfollowing:

– High Fear-Avoidance or Anxiety

have you often been bothered by feeling down, depressed, or hopeless?”

– “During the past month, FABQ-PA: Sum 2-5

Cutoff >14 FABQ-W: Sum 6-7, 9-12, 15

Cutoff >29

During the past month, have you often been bothered by little interest or pleasure in doing Cutoff >29

– High Pain Catastrophizing Scale scores Rumination: 8 11

p gthings?” 2 no answers = -LR of

0.07 Rumination: 8-11 Magnification: 6-7,13 Helplessness:1-5,12

Delitto et al, JOSPT 201210

Classification Reliability and Utility

Reliability– K = 60 when traction removed (paper assessment)K .60 when traction removed (paper assessment)

Fritz et al 2006– K = .52 for all groups (individual assessment)

Stanton et al PT 2011 Stanton et al, PT 2011 Utility

– Classification versus clinical practice guidelines or unmatched careunmatched care

– Significant improvements in pain, disability, general health, satisfaction, and likelihood of returning to work in matched classification group (4 wks & 1yr)work in matched classification group (4 wks & 1yr) Fritz et al 2003; Brennan et al 2006

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Prevalence Data

50% of patients meet criteria for one bsubgroup

Of remaining 50%...– 25% cannot be classified (myofascial pain?)– 25% fit >1 classification

68% of these individuals fitting manipulation/specific 68% of these individuals fitting manipulation/specific exercise

Stanton et al, PT 2011 (acute); Apeldoorn et al, Spine 2012 (chronic) (c o c)

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Beyond the “old” TBC…

Classification often unclear in patients who are older, chronic less affected by LBP (FABQ and ODI) St tchronic, less affected by LBP (FABQ and ODI) Stanton et al 2013

Treatment by “old” TBC criteria yielded equivocal outcomes to an individualized approach (Dutch LBP guidelines) (Apeldoorn et al 2012) and did not reveal a preference for matched care in the stabilization pcategory (Henry et al 2014) in patients with CLBP

New ICF guidelines represent the best attempt yet to id id ti f di ti l fprovide considerations for directional preferences,

regional interdependence, and chronic pain states13

PAIN-DOMINANT TREATMENT

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Pain-Dominant Treatment

ContractileM f i l i d– Myofascial pain syndrome

Non-contractile– Acute to subacute LBP with

referred/radiating pain Lumbar spine stenosis Cauda equina syndromeq y Herniated disc HNP with radiculopathy Sciatica

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Comprehensive Treatment for Pain

Tissue-Specific Rx Generalized Rx– Contractile

Soft tissue mobilization Dry needling

– Relative rest– Education

M d litiy g Submaximal isometrics

– Non-contractile Graded mobilization

– Modalities– Short-term orthosis– Exercise Graded mobilization

Graded spinal ROM (directional pref)

Spinal traction

– Exercise– Relaxation/Breathing– Cognitive behavioral Spinal traction

Neural gliding/tensioning

gtherapy

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Myofascial Pain Syndrome

Environmental/Emotional/PhysicalErgonomics (short upper arms)– Ergonomics (short upper arms)

– Stress – Hormone and Vitamin deficiencies

Structural misalignment (legs and– Structural misalignment (legs and pelvis)

Mechanical– Underlying facilitated segment or

thoracolumbar joint dysfunction– SI joint dysfunction

(Iliopsoas/Quadratus)– Synergist/agonist strengthening

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Support for Myofascial Pain Management

Non-specific low back pain (13 studies)“M i ht b b fi i l f ti t ith b t– “Massage might be beneficial for patients with subacute and chronic non-specific low back pain, especially when combined with exercises and education.” Furlan et al Cochr Syst Rev 2008 Furlan et al, Cochr Syst Rev 2008

Myofascial low back pain– Support for multimodal treatment including massage,

correction of muscle imbalance, and dry needling Malanga and Cruz, Phys Med Rehabil Clin N Am 2010 Furlan et al, Spine 2005

Currently no high quality evidence supporting the use of US for improved pain/QOL

Ebadi et al., 201418

Acute to Subacute LBP with Referred/Radiating Pain Management

DiscG d d ROM (S ifi E i )– Graded ROM (Specific Exercise)

– Graded Axial distraction (Traction)

Nerve– Graded ROM

Specific Exercisep Neural gliding

– Painfree (Acute)– Mid to end-range (Subacute)

– Graded Axial distraction

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Specific Exercise Philosophy

Achieve centralization of patient’s referred

ipain Patient-directed

approach consisting of McKenzie-basedMcKenzie-based techniques

Perform movements in opposite direction once ppmovement no longer creates peripheralization

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Specific Exercise - Extension

PositioningP ti t l i– Patient prone lying or prone on elbows

– Useful when movement peripheralizes sx Typically acute Hold positions for

minutes

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Specific Exercise - Extension

ROM– “Passive” movements

Prone press up Standing back bends Standing back bends

– Perform in sets of 10 until sx centralization l tplateaus

– Perform as many times as neededtimes as needed during the day

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Specific Exercise - Translocation

PositioningSidelying on the side– Sidelying on the side describing the shift Pillows under thorax to

encourage pelvic translocation

– Prone with pelvic translocation

St di l t l hift Standing lateral shift correction

– “Active” ROM

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Specific Exercise - Translocation

Standing lateral shift correctioncorrection

– “Passive” ROM with therapist– “Active-assist” ROM on lat

bar with manual correctionbar with manual correction

Patients beginning with a translocation preference will typically favor extension at some point

– Laslett, JMMT 200924

Specific Exercise - Flexion

PositioningS i h k l i– Supine hook lying

– Supine 90/90– Seated forward bend

“Passive” ROM– Quadruped flexion– Bilateral/unilateral knees to chest

“Active” ROMStanding/Seated lumbar flexion– Standing/Seated lumbar flexion

– Post pelvic tilts25

Subacute Management of Referred/Radiating Pain

Specific exerciseS lf t t t t h i– Self treatment techniques should be exhausted before application of therapist assistedtherapist-assisted technique

– Therapist assistance provided via positioningprovided via positioning, PA mobilization, overpressure, or soft tissue mobilizationtissue mobilization

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Subacute Management of Referred/Radiating Pain

Extension therapist-assisted t h itechniques – Overpressure

Stabilization of pelvis during prone press Stabilization of pelvis during prone press ups

– Extension mobilizationPA l l th t id f bl PA over level that provides favorable response

Followup with prone press ups

L t l t t– Lateral compartment Pelvic translocation away from pain side Maintain position during prone press ups27

Subacute Management of Referred/Radiating Pain

Flexion therapist-i t d t h iassisted techniques

– Soft tissue mobilization or overpressure whileor overpressure while patient is in position of flexion

– Best applied in Quadruped Leaning over edge of Leaning over edge of

table Sitting28

Support for Directional Preference

Systemic review supports short term to intermediate

Patients given exercises matched to their movementshort term to intermediate

benefits (Claire et al. Aust J Physiother 2004; Machado et al. Spine 2006; Surkitt et al.

matched to their movement preference improved significantly in pain, med use, disability (Long et al, Spine p

PT 2012)– Moderate evidence DPM

superior to multidirectional

y ( g p2004)

mid-range exercises, stretches, and advice in those with DPConflicting evidence when– Conflicting evidence when DPM compared to manual therapy and strengthening

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Support for Centralization

Patients centralizing with repeated movements

Patient experiencing reduced pain levels (≥repeated movements

– SE and mobilization superior to stabilization for

i /di bilit t 1 k

reduced pain levels (≥ 2/10) with mobilization and prone press ups

pain/disability at 1 week, disability at 4 weeks and 6 months Browder et al. JOSPT 2007

demonstrated concurrent increase in disc water diffusion Beattie et al, 20102007

– SE superior to manipulation for patient reports of success (2mos) and

diffusion Beattie et al, 2010

Rates of centralization in other CPR categories

success (2mos) and disability (2mos/12mos) Petersen et al 2011

– Manipulation = 68%– Stabilization = 80%

Werneke et al, 201030

Spinal Traction Philosophy

Achieve centralization of patient’s referred pain Patient directed Patient-directed

– Positional Maximum IVF opening with flexion, side bending contralateral,

rotation ipsilateralrotation ipsilateral– Creighton JMMT 1993

Therapist-directed Manual– Manual

– Mechanical

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Spinal Traction

Effective parameters i th lit tin the literature– 30-60% body weight

Static or intermittent– Static or intermittent (3:1) duty cycle

– 12-15mins– Supine or prone

Cai et al 2009, Fritz et al 2007 Saundersal 2007, Saunders 1993

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C fli ti S t f T ti Conflicting Support for Traction (General LBP)

Traction efficacy (pain and disability) not endorsed indisability) not endorsed in systematic reviews for mixed samples of LBP

– Macario and Pergolizzi, Pain Pract 2006; Clark et al, Spine 2006

Physiological effects arePhysiological effects are supported

– Widens IVF/Stretch posterior spinal elements (Lehmann et al 1958)elements (Lehmann et al 1958)

– Creates negative intradiscal pressure (Ramos et al, J Neurosurg, 1994)33

Support for Traction

Population: Lumbar Radiculopathy Intervention: Lumbar extension exercises (6 weeks) Intervention: Lumbar extension exercises (6 weeks)

versus lumbar extension protocol with traction (2 weeks) Significant improvements in disability and FABQ favoring g p y g

traction group at two weeks Improved outcomes and sustained changes in subgroup at six

weeksPositive crossed leg raise (<45deg)– Positive crossed leg raise (<45deg)

– Lower extremity pain that peripheralized with extension Fritz et al 2007

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S b t LBP ith R di ti (NSubacute LBP with Radiating (Non-Peripheralizing) Pain Management

Neural glidingGeneralized PT program– Generalized PT program (aerobic exercise, global PRE, and PA mobilization) versus Generalized PT with Slump stretching (30secx5), 2x/week x 3 weeksSlump group improved– Slump group improved disability, pain compared to control Cleland et al 2006 Nagrale et al 2012

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Acute to Subacute LBP with Referred/Radiating Pain Management

Contributing Impairments (Env.) E i– Ergonomics Encourage positioning into specific

exercise movement preference

– Weight bearing Wheeled walker: >250% increase in

self reported walking distance in 71%self reported walking distance in 71% of subjects

Goldman et al, J Fam Pract 2008

Walking stick: no significant Walking stick: no significant improvement in walking tolerance

Comer et al, Arch Phys Med Rehabil 201036

Acute to Subacute LBP with Referred/Radiating Pain Management

Contributing Impairments– Mechanical

Mobilization of hypomobile segments above/below levelg

– Tightness opposite specific exercise movement preference

Mobilization of nerve interface points

Strengthening of hypotonic lumbopelvic muscles to address underlying instability

– Weakness into specific exercise movement preference37

S t f C t ib ti I i t Support for Contributing Impairment Management

Population: Lumbar Spine Stenosis

Intervention: Flexion-based program with progressive walking program versus manual therapy p g pyto hips and spine with PRE and unweighted treadmill ambulation (6 weeks)

Si ifi t i t i di bilit– Significant improvements in disability and pain at 6 weeks, 1 year, and 29 months in both groups

– Improved perceived recovery in p p ymanual therapy group (79% vs 41% at 6 weeks) Whitman et al Spine 200638

S t f C t ib ti I i t Support for Contributing Impairment Management

Population: Subacute to chronic back-related LE pain (not stenosis)p ( )

Intervention: ROM and stabilization exercise versus manual therapy (including thrust) with ROM and stabilization exercise (12 weeks) ( )

– Significant improvements in disability, pain, medication usage, satisfaction, global improvement, and medication use at 12 weeksMaintained satisfaction global improvement and meds at 1– Maintained satisfaction, global improvement, and meds at 1 year Bronfort et al, 2014

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STIFFNESS-DOMINANT TREATMENT

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Treatment Considerations

Primary treatment for patients in Acute to Chronic LBP with Mobility Deficits categoryLBP with Mobility Deficits category

– Classification for patients with undifferentiated pain– May address a mixture of myofascial, joint, or neural limitations

in motion

Primary treatment for addressing motion loss in patients without a chief complaint of painpatients without a chief complaint of pain

Reduced manual emphasis in Acute LBP with Related Cognitive or Affective Tendencies and Chronic LBP with Related Generalized PainChronic LBP with Related Generalized Pain

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Spinal Manipulative Therapy (SMT)Spinal Manipulative Therapy (SMT)Cochrane Reviews

In general, SMT not superior to inert treatment sham SMT orinert treatment, sham SMT, or other active treatments in acute or chronic heterogeneous LBP subjects

– Rubinstein et al 2013 (acute)– Rubinstein et al 2011 (chronic)Rubinstein et al 2011 (chronic)

Thrust equal to non-thrust in CLBP (Cook et al 2013) and adults 5555+ (Learman et al 2013)

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Acute LBP with Mobility Deficits

CPR for lumbar manipulation– Duration of symptoms < 16 days *y p y– No symptoms distal to the knee *– At least one hip with > 35° of IR– Hypomobility with lumbar PAIVM

t titesting– FABQ(W) < 19

4/5 criteria Posttest probability of success increased from 44% toof success increased from 44% to 92% (+LR=13.2)

Flynn et al, Spine 2002; Childs et al, Ann Intern Med 2004

CPR has been Validated! 43

In Patients Fitting the CPR…

Expect a good prognosis regarding ODI change, NPRS change # visits extent of recovery C k t l 2013change, # visits, extent of recovery Cook et al, 2013

Thrust technique (lumbopelvic or lumbar rotation) does not matter

Range of inferior to equal outcomes for nonthrust techniques Cleland et al, 2009; Learman et al, 2014

Equivocal outcomes between repeated end range movements and manipulation Schenk et al, 2012

End range may be what’s most important! End range may be what s most important!

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Inability to Respond to Manipulation

Longer duration of symptoms Symptoms in the buttocks or Symptoms in the buttocks or

leg Absence of hypomobility/pain

on mobility testingon mobility testing Less discrepancy in the left to

right hip IR ROMN ti G l ’ i Negative Gaenslen’s sign

Peripheralization with motion testing

F i l PT 2004– Fritz et al, PT 2004

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Chronic LBP with Mobility Deficits

Case series8 ti t ith h i– 8 patients with chronic LBP and hip stiffness in at least 2 planes3 i it f hi bili ti– 3 visits for hip mobilization and hip stretching

– 62.5% rated improvement d t l b ttas moderately better or

higher on GROC– 24.4% improvement on

ODIODI Burns et al, JMMT 2011

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Chronic LBP with Mobility Deficits

RCT investigating non-region specificregion specific manipulation for CLBP

Immediate pain preduction for T1-T5 manipulation comparable to L2-L5comparable to L2-L5 manipulation

– De Oliveira et al., PT 2013

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PRIMARY INSTABILITY IMPAIRMENT

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Treatment Considerations

Primary treatment for patients in Acute to Chronic LBP with Movement Coordination ImpairmentsLBP with Movement Coordination Impairments category

– Classification for patients with undifferentiated pain– Treatment primarily focused on contractile tissue

neuromuscular re-education/strengthening at the site of pain

Secondary treatment for patients in all otherSecondary treatment for patients in all other categories, especially Acute LBP with Referred LE Pain

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Examples of Education for Joint Instability

SleepingPill b t th k d– Pillow between the knees, under the lateral trunk, or anterior to trunk

– Medium mattress preferred to firmK t l 2003 Kovacs et al, 2003

Sitting– Foot supportpp– Lumbar support– Arm support

LS corsets LS corsets– Equivocal findings for management

van Duijvenbode et al, 200850

Overview of Exercise Progression

Strengthening of lumbar spine away from

Stretching of thoracic spine and hips spine intospine away from

syndrome– Avoids aggravation

spine and hips spine intosyndrome

Motor control of lumbar associated with loading into DSM

– Begin with isometrics of

spine into syndrome– Ensures activation of

weakest synergist(s)deep stabilizers, progress to superficial muscles

– Teach patient how to use

weakest synergist(s)– Teach patient how to use

hip and thoracic regions more

lumbar region moremore

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Examples of Initial Treatment for Joint Instability

Independent activation d t i h ldand tonic hold

– Pelvic floorTRA (extension syndrome)– TRA (extension syndrome)

– Lumbar multifidus isometrics (flexion (syndrome)

– Glutes (rotation syndrome)

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Examples of Progressive Treatment for Joint Instability

Integrated tonic hold– Iliopsoas

strengthening (flexion syndrome)syndrome)

– Glut max and thoracic extensor strengthening ( t i d )(extension syndrome)

– Hip versus lateral trunk strengtheningtrunk strengthening (rotation syndrome)

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Recruitment of Abdominal Muscles

Drawing-in maneuver and Bird-dog (TRA)(TRA)

Posterior pelvic tilt and abdominal bracing (IO)

Side plank and Abdominal crunch (Both) Side plank and Abdominal crunch (Both)– Urquhart et al, Man Ther 2005; Teyhen

et al, JOSPT 2008 Hollowing during typical exercises Hollowing during typical exercises

increases TRA recruitment from 4-43%– Bjerkefors et al, Manual Therapy 2010

Adding ankle DF to drawing in led Adding ankle DF to drawing-in led to greater gains in pain/function

– You et al, Clinical Rehabilitation, 2013 54

Recruitment of Gluteals over TFL

ClamN t l ( ti l) l i– Neutral (vertical) pelvis maximizes G med/max activationG d i i d t 60d hi– Gmed maximized at 60deg hip flexion

Sidestepping Unilateral bridge Quadruped hip extension

with bent/straight kneewith bent/straight knee– Willcox & Burden, 2013; Selkowitz

et al, 201355

Chronic LBP with Mobility DeficitsA Meta Analysis and RCT

Motor control exercise was superior to general exercise manual therapy and minimal interventionexercise, manual therapy, and minimal intervention for the reduction of pain and disability at variable time intervals, depending on the comparison condition

– First evidence suggesting widespread application of this procedure in heterogeneous samples of CLBP subjects (Bystrom et al, 2013)

No added benefit to matching motor control deficit to exercise preference in CLBP using Sahrmann categories (Henry et al 2014)categories (Henry et al. 2014)

– Lack of evidence for matched stabilization treatment in ALBP or chronic widespread pain56

Acute LBP with Mobility DeficitsAcute LBP with Mobility DeficitsA Systematic and Cochrane Review

Evidence for general exercise programsp g

Systematic Review: Acute LBP

– Equivocal results for qexercise compared to other interventions in acute population (C) Lawrence et al, 2008 Lawrence et al, 2008

Cochrane Review– Moderate quality evidence

that post-treatment exercise program can prevent recurrence of low back pain Choi et al, 201057

A t LBP ith M bilit D fi itAcute LBP with Mobility DeficitsWho Needs Motor Control Approach?

CPR for lumbar stabilizationAge < 41 years *– Age < 41 years

– Positive prone instability test– Aberrant motion

SLR > 91°– SLR > 91 3/4 criteria (LR+ = 4.0) Validation study failed to completely

support CPR (underpowered?)support CPR (underpowered?)– Modified CPR of + PIT and aberrant

movement may provide better predictive validitypredictive validity

Hicks et al, Arch Phys Med Rehabil 2005; Rabin et al, JOSPT, 201458

Motor Control Exercise in Motor Control Exercise in Radiographic Instability

Population: Spondylolysis or spondylolisthesisp y

Intervention: Stabilization program with TRA and multifidus focus versus t t t di t d b PTtreatment as directed by PT (10 weeks)

Significant improvements in disability and pain at y p10 weeks and 30 months in stabilization group

O’Sullivan et al, Spine 1997

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Inability to Respond to Stabilization

Discrepancy in SLR ROM >10deg A ld t l 2012>10deg Apeldoorn et al, 2012

_____________________ Negative prone instability test Negative prone instability test Hypomobility with PAIVM

testing Aberrant motion absent FABQ(PA) score ≤ 9

2/4 criteria SN 85 SP 87– 2/4 criteria SN = .85; SP = .87– Hicks et al, Arch Phys Med Rehabil

200560

Summary of Recommendations:Acute-Chronic LBP with Movement Impairments

EducationS ti t

PREF ti l t– Supportive postures

– Ergonomic activities– Temporary bracing (acute)

– Functional movements– Gym-based activity– Pilates

Motor control exercise– Begin with isolated

contractions and holds

Manual therapy to thoracic spine, ribs, sacrum and hipscontractions and holds

– Progress to isotonic open/closed chain loadingGraded dosing: 2min total

sacrum, and hips Progression to work

reintegration programs – Graded dosing: 2min total

time under tension as neededDelitto et al, JOSPT 2012

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S mmar of RecommendationsSummary of Recommendations:Acute LBP with Related Cognitive or Affective Tendencies and Chronic LBP with Related Generalized Pain

Education– De-emphasize pathology

Fitness– Low intensity, submaximal p p gy

– Emphasis on anatomical strength of spine

– Neuroscience of pain

y,fitness and endurance activities for above mentioned categories– Neuroscience of pain

– Overall favorable prognosis of LBPStrategies to limit fear and

– Moderate to high intensity exercise for CLBP without generalized pain

– Strategies to limit fear and catastrophizing (CBT)

– Emphasis on increasing activity capacity not just

Exercise– Graded stabilization ≥

Graded functional activityactivity capacity, not just pain relief

– http://www.youtube.com/watch?v=4b8oB757DKc

Graded functional activity

Delitto et al, JOSPT 201262

G d d F ti l A ti iti Graded Functional Activities vs Stabilization

Graded functional ti it t

Graded stabilization dactivity versus motor

control exerciseNo significant

program compared to general walking program– No significant

difference between groups at 2, 6, and 12

program– 55% success (stab)

versus 26% success months Macedo et al, PT 2012

(walk) at 12 and 36 months Rasmussen Bar et al Rasmussen-Bar et al,

Spine 2009

63

Lumbar Spine Instability Questionnaire

“Give way” or “give out” Self manipulation

Muscle spasms common Fearful of movement Self-manipulation

Frequent pain in the day Back catches or locks

Fearful of movement Trauma MOI in the past Long duration of problem

Pain with sit to stand Pain with supine to sit Painful quick, unexpected,

Positive test is ≥ 9/15 Predictive of which CLBP q p

mild movements Need back support in chair Pain with sustained posture

patients respond best to motor control over graded exercise Pain with sustained posture

Worsening over time Temporary relief with corset

Macedo et al., 2014

64

Aquatic Therapy in CLBP

5x/w x 4w supervised 60min aquatic program to comparably dosed unsupervised land HEPdosed unsupervised land HEP

Both groups improved; Statistical (not clinical) significant difference in ODI and QL scores

– Dundar et al Spine 2009– Dundar et al, Spine 2009 2x/w x 6w supervised 60min aquatic versus land program Both groups improved pain/function, no differences

Sj Ph i th R I t 1997– Sjogren, Physiother Res Int 1997 Systematic review supported benefits

in CLBP and pregnancy– Waller et al, Clin Rehabil 2009

65

POST-SURGICAL MANAGEMENT

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Overview

Pain/Pathology focus is patient dependent, ll li it dusually limited

– Cryotherapy/TENS for post-surgical painI i t f i k Impairment focus is key– Stabilization

Neural gliding– Neural gliding– Conditioning– Spinal ROMSpinal ROM– Mobilization away from surgical site

Cioppa-Mosca et al, 2006; Maxey and Magnusson 201367

Lumbar Fusion Types

InstrumentedP t l t l f i– Posterolateral fusion Disc preserved Most common

M ltifid ti l d ti Multifidus partial denervation– Anterior lumbar interbody fusion

Disc resected Circumferential fusion Oblique partial denervation

– Cage fusion Disc resected Interbody fusion only

68

Lumbar Fusion Rehab Considerations

Outpatient therapy typically begins at 6 10 weeks post opat 6-10 weeks post-op

Precautions– No iliopsoas stretching until 8 weeks p g– No lifting >10lbs or overhead until 12

weeks– No lumbar standing ROM testing orNo lumbar standing ROM testing or

iliopsoas MMT until ready for return to sport (typically 20 weeks)

– No US over healing fusionNo US over healing fusion– No end range extension for 6 months

(cage)69

Lumbar Disc Surgical Procedures

Disc replacementA t i h i t t– Anterior approach consistent with cage fusion

Lumbar discectomy– Microscopic or open– Lamina removal variable– Multifidus partial denervationMultifidus partial denervation

possible

Minimally invasive percutaneous techniquepercutaneous technique

– Chemonucleolysis– Percutaneous discectomy70

Lumbar Disc Rehab Considerations

Outpatient therapy typically begins at 4-6 weeks post opweeks post-op

Discectomy Precautions– Limit lumbar flexion stress– No lumbar standing ROM or slump testing until 6th

week– Running and return to sport between 8-12 weeksRunning and return to sport between 8 12 weeks

Replacement Precautions – Limit lumbar extension stress– No lumbar standing ROM or PAs

until 6-8 weeks– Return to sport 13-24 weeks71

Lumbar Surgery General Guidelines

Body mechanics Stabilization Stabilization

– All positions Conditioning

Bik t d ill– Bike, treadmill Stretching

– Hip and leg muscles– Scar mobility– Thoracic/Hip joints– Neural mobilization– Lumbar spine

Strengthening (discectomy)– Back extensors (Kulig et al 2009)72

Support for Post-Operative PT

Cochrane Review: 14 trials, status post discectomy or microdiscectomy (Ostelo et al 2009)microdiscectomy (Ostelo et al 2009)

– Moderate quality evidence Exercise more effective than no treatment at improving disability High intensity exercise more effective than low intensity exercise High intensity exercise more effective than low intensity exercise

– Low quality evidence + effects of exercise (regardless of intensity) on pain Negligible effects of neural gliding short-long termg g g g g Home and supervised programs yield same short term results

8 week exercise program administered 2 weeks post-op discectomy (Hebert et al 2015)op discectomy (Hebert et al, 2015)

– No difference in general vs specific exercise programs on clinical outcomes or multifidus function at 10wks or 6mos 73