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TABLE 16-1 The Degenerative Cascade

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Damage at Each Stage

Structure Stage l: Dysfunction Stage 2: Instability Stage 3: Stability
m

lntervertebral disc 0 Circumferential tears 0 Radial tears 0 Loss of proteoglycans and water, fibrotic resorbtion
0 Inflammatory exudates and irritation 0 Loss of disc height 0 Sclerosis and eventual bony ankylosis
0 Internal disruption
0 Disc bulges and herniations
Facet ioints 0 Synovitis 0 Laxity of ioint capsule 0 Significant bony overgrowth
0 Minor cartilage degeneration 0 Moderate cartilage degeneration 0 Grossly degenerated cartilage
Muscles 0 Spasm, guarding 0 Chronic shortening and fibrosis 0 Further shortening and fibrosis
Neural foramen 0 Unaffected 0 Narrowed through annular bulges 0 Significant stenosis
0 Disc narrowing 0 Disc narrowing
0 Bony overgrowth
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Lumbar Fusion“ anld'“Lwaimminectomy

Rehabil'it'ati'on Criteria to Progress Anticipated Impairments
Phase
WW. to This Phase and Functional Limitations Intervention , . Goal Rationale

.
Phase II 0 Outpatient candidate 0 Pain limited with ADL 0 Cryotherapy Independent with the following: 0 Self-manage pain
Postoperative 0 No signs of infection 0 Limited nerve root mobility 0 Relative rest I. Bed mobility 0 Prevent reiniury
6-I0 wk 0 Cleared by physician 0 Limited Trunk stability 0 Review of body mechanics Training 2. Don/doff clothing, and corset if indicated 0 Perform .ADL without adding increased
to begin therapy 0 Limited mobility of regions 0 Nerve mobilization 3. Transfers stress to the lumbar spine
adiacent To surgical site *9 PROM/LE end LEE stretches: 4. Gait, using assistive device as appropriate 0 Prevent neural adhesions
0 Limited endurance and Hip iexei‘s (gently initiate after 8 wk with 0 Demonstrate appropriate body 0 Improve mobility of LB to decrease
Tolerance To physical activity on",vs‘i;.‘irirt eeer.'uval) mechanics with self-care and basic ADL stress on the lumbar spine
Gluteeis 0 Demonstrate proper motor control using 0 Initiate trunk stabilization while
Hip E'Dfilffl‘SS transverse abdominis, pelvic floor, and performing AOL to decrease potential
Quintin:-eo-s multifidus for reiniury
0 Demonstrate bracing and begin to 0 Perform cardiovascular conditioning
incorporate this with activities and "tiny steps” to avoid excessive
lumbar spine movement during gait
I-nr rs'c-rt with active range of motion: 0 Improve mobility of thoracic spine to
ribdominai e“'racing with squats, transfers, and gait decrease stress on the lumbar spine
e» Spinei exercises: 0 Improve mobility of soft tissue
Bridg-tog; 0 Reduce volitional muscle guarding
Dying bug (att’er 8 wk, with physician approval) 0 Perform cardiovascular conditioning
Quadruped octivities
Superman (after 8 wk, with physician approval)
Prone (much later in phase, with physician
approval)
0 Walking program
0 Joint mobilization to upper and mid T/S,
gentle if mobilizing lower T/S
0 Soft tissue massage after incision is closed
0 Patient education
0 Upper body ergometer
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TBLE and Laminectomy

Criteria to Anticipated
Rehabilitation Progress to Impairments and
Ph_—_——___________________Wse
This Phase Functional Limitations Intervention Rationale

Phase III 0 No increase in 0 Mild pain Continue intervention from phase II 0 Independent with 0 Promote return to
Postoperative pain 0 Limited tolerance to as indicated most ADL independent lifestyle
I I-I9 wk 0 Improved upright positions 0 Isometrics with active range of motion 0 Increased trunk and 0 Develop kinesthetic sense
Tolerance to (sit/stand) Abdominal bracing with the following: extremity strength for the muscles and their
upright postures 0 Limited trunk, lower Bridging 0 Maintenance of role in protecting the
extremity, and upper Dying bug neutral spine while spine
extremity strength Quadruped with performing 0 Improve the ability to
Heel lifts strengthening brace the spine and
Superman (avoiding lumbar spine exercises maintain a neutral
extension) 0 Performance of 20-30 position
Scapular depressions minutes of 0 Increase strength of trunk
Push ups cardiovascular exercise and extremities to avoid
0 Progressive resistance exercises: daily excess stress on the spine
Lateral pull-downs 0 Start weight training to
Seated upright/rows triceps dips begin hypertrophy of
0 Cardiovascular conditioning associate musculature
0 Stair stepper upper body ergometer 0 Promote good
0 Brisk walking cardiovascular fitness
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Anticipated
Criteria to Impairments and
Rehabrl'rt'atr'on Progress to This Functional
Phase
w, Phase Limitations Intervention Rationale

Phase IV 0 No increase in pain 0 Limited trunk and Continue exercises from 0 Return to work 0 Patients with sedentary iobs
Postoperative 20 0 No loss in extremity strength previous phases as indicated 0 Increase trunk and should be able to resume
wk-l year functional status 0 Limited tolerance to 0 Advance exercises with extremity strength their schedule
0 Patient has sustained postures regard to repetitions and 0 Increase muscular 0 Continue reconditioning to
decreased reliance 0 Mild pain weight endurance an expected level of function
on formal Therapy associated with 0 For appropriate patients, 0 Prepare to return to while protecting
0 Clearance from activities initiate running, cutting, and more strenuous activities the spine
physician for 0 Limited with lifting iumping progression. This 0 Return to previous level 0 Carefully apply stress to the
progression to and carrying would not he in.we"Ere‘ted in a of activity as appropriate body in tolerable doses to
phase IV meiori'rgi Ifr"«"sf’l. :l."5if? loss”: a 0 Discharge patient to increase the spine's ability
patients- self-management of to withstand stress
0 Specific refilated flare-ups 0 Evaluate the ability to return
to home, ‘11:} if
bwln, or spert 0 Improve trunk strength to previous function
environment to previous levels of 0 Because patients with
0 Functional capacity functioning lumbar spine fusion may
evaluation continue to have problems
0 Continue progression of with ioints above and below
interventions in phases ll the fusion site, continuation
through IV of some level of
0 Progress home exercises maintenance must be
0 Continue patient education emphasized
with regard to activity 0 Fusion patients must also
modification and performance maintain constant body
with ossistive device awareness, always using
proper body mechanics
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 Suggested Home Maintenance for the Postsurgical Patient

Days 1 to 5 and up to starting . Calves (gastrocnemius and soleus)

outpatient therapy . Adductors
GOALS FOR THE PERIOD: Educate patient about Piriformis
simple movements, teach nerve mobilization and . Hip flexors (gently initiate only with

(07th
light isometric abdominal contraction, review home physician approval)
care principles h. Latissimus dorsi
1. Gentle nerve gliding 7. Initiate gentle balance activities
2. Initiate abdominal isometric contraction (TA,
pelvic floor) Weeks 11 to 19
3. Walking daily as tolerated (should slowly increase GOALS FOR THE PERIOD: Increase activity,
in time and speed) emphasize tissue modeling, stabilization,
Consistent use of proper body mecham'cs reconditioning, weight programs, and return
Icing as needed to work
Protection of incision 1. Progress walking tolerance to 30 to 60 minutes
Ankle pumps and c‘..¢.-~'.;* * daily
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prevention 2. Increase aggressiveness of stabilization

program slowly and to patient’s tolerance
Weeks 6 to 10 Supine marching
GOALS FOR THE PERIOO: initiate outpatient therapy, . Bridging
perform a thorough evaluation (avoid LS ROM and Dying bug
resisted hip flexion), patient education, neural . Squats (to 90° of knee flexion)
mobilization, abdominal stabilization, begin . Ouadruped
conditioning activities and home care principles Prone over pillow or exercise ball
1. Progress walking tolerance to 20 to . Planks (half progressing to full) front and
corho po'pa
30 minutes side
2. Isometric stabilization . Continue to maintain nerve root mobility
a. TA, pelvic floor, mulifidus . Initiate resistance training using weights
#00

b. Abdominal breathing, hollowing, bracing (generally after 12 weeks)

c. Bracing during light functional a. Seated upright rowing machine
movements b. Latissimus pulls
. Initiate light strengthening exercises c. Scapular depressions
a. Wall slides (to approximately 60° of knee d. Dips
flexion) . Continue cardiovascular training using the
b. Side-lying hip rotation following:
4. Reinforce body mechanics a. Stair climber
5. Continue neural mobilization b. Brisk walking
6. Begin stretching hips, LEs, and shoulders while c. Standing or floatation device—assisted pool
maintaining bracing exercises
a. Hamstrings
b. Ouadriceps
c. Gluteals
Week 20 and Beyond 4. Develop gym or home program for
GOALS FOR THE PERIOD: Restore preinjury status, independent management that should include
continue home program of conditioning and the following:
stabilization a. Cardiovascular exercises
1. Progress stabilization program to level b. Stabilization exercises
required by patient’s activity level :2. Strengthening exercises
2. Continue to work on hip, LE, and shoulder d. Flexibility exercises
flexibility 339gin sport—specific drills or work-specific
3. lnitiate light LS flexibility exercises with proper." :~'ai‘:‘t§m‘t‘g,’ imfer to examples in Chapter 14)
form