Provocative discography can be a useful diagnostic tool in the work-up of patients with painful degenerative lumbar disc disease. The lumbar discs are deep within the abdominal cavity and do not have true dermatomal pain patterns in axial discogenic cases. Overlapping sclerodermal referred pain patterns in the lumbar spine make the localization of the true pain generator difficult. Discography has evolved as a test to examine the lumbar discs morphologically and, most importantly, provocatively. On injection into the disc, the patient must communicate to the discographer if that disc is concordantly painful. Many degenerative discs are either not painful or discordantly painful. This information can be useful for the surgeon and the patient contemplating lumbar arthrodesis. The test is not used as frequently as in the past, as authors have described conflicting results and there is emerging concern that the injection itself may cause eventual disc deterioration.10

Today, most spine surgeons use pedicle screw constructs to immobilize the vertebrae rigidly while preserving the normal lumbar lordosis2 (Fig. 16-1). Typically, external orthosis bracing is not needed in these cases. As well-controlled studies emerge, data support the use of internal fixation for fusion.¹¹ Most studies support the use of pedicle screw fixation to obtain a more reliable bony union, although complication rates tend to be higher with these devices as well.^12,13

Some surgeons do not routinely use pedicle screws for arthrodesis. In most of these situations (when pedicle screws are used) the patient must wear a lumbar orthosis for an extended period postoperatively. To immobilize the L5 to S1 motion segment effectively, an orthosis with a thigh-cuff extension must be applied. Patients with noninstrumented fusions may take an extensive amount of time to stabilize and become comfortable in their rehabilitation. Conversely, most patients with internal fixation become mobile and independent more rapidly, making early rehabilitation more predictable.

Opinion about the degree of rehabilitation needed after spinal surgery ranges from the optimistic view that no rehabilitation is needed to others who argue for aggressive exercise- and education-based programs. As noted earlier there has also been mounting evidence that failing to address psychosocial factors in this population may also be neglecting an integral part of the rehabilitation and recovery process. This chapter is written from the point of view that the patient who has undergone surgery needs not only a program that will protect the surgical area and create an effective healing environment, but also addresses relevant and contributing changes in motor control dealing with both the active subsystems and neural control subsystems as outlined by Panjabi18,19 (Box 16-1). Although the surgery itself deals with improving the passive subsystem, which include such anatomic structures as the vertebral bodies, facets, and ligaments, capsule, it is our job as specialists in rehabilitation to address these other systems.²⁰ It is also important to realize that those 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.

The following guidelines are not intended to substitute for sound clinical reasoning but rather serve as a foundation on which a trained physical therapist (PT) can base the rehabilitation of a patient after spinal fusion. It is assumed that the therapist will know the basics of spine and extremity evaluation in order to monitor the patient for symptoms that require prompt reevaluation, along with addressing relevant contributing factors in other body regions that have a significant impact on the lumbar spine.

Before an individual elects to undergo lumbar spinal fusion, it is generally assumed that conservative measures have not had a significant impact on the patient’s condition and that they have gone through an extensive therapy program. Hopefully the individual has been taught stabilization-based exercises and has begun to address other relevant physical and cognitive dysfunctions. Once surgery is deemed necessary by the patient and rehabilitation team, 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:

An effective preoperative program before lumbar fusion surgery should also address any other relevant patient concerns and include other advice from the members from other disciplines included in the rehabilitation team. 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 For the rehabilitation specialists, an understanding of the specific procedure performed is essential for safe rehabilitation. Before beginning a rehabilitation program, the therapist must know whether the patient has had a fusion with or without instrumentation. Patients who were operated on with instrumentation can generally be progressed more aggressively in the first phase of rehabilitation. Patients who were operated on without instrumentation require more time for the bony fusion to take place. Generally a callus should form within 6 to 8 weeks; the surgeon monitors this by radiograph and usually does not refer to outpatient therapy before a callus has formed. The therapist also must know the surgical approach and the levels fused. After a motion 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).

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 floor muscles and watch for any substitution patterns to promote proper spinal stabilization.

GOALS: Patient education about daily movements, abdominal stabilization, neural mobilization, and home care principles (Table 16-2)

GOALS: Increased activity, tissue remodeling, stabilization, and reconditioning (Table 16-3)

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.

Patients progressing to the latter portion of phase II increase the intensity of the stabilization program begun in the earlier stages of the phase. They may increase repetitions and level of difficulty. 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. Patients should no longer require assistance with most daily activities.

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.

Body Mechanics Training

If body mechanics training was provided preoperatively, then it should be reviewed after surgery. If body mechanics training is new to the patient, then 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)

Patients must perform these activities to get dressed, use the bathroom, travel to physician’s appointments, and shop for and prepare meals. A patient who can do these activities without stressing the surgical site will heal faster and with less discomfort. Patients can accomplish all these tasks without lumbar 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 maneuvers makes the postoperative transition easier. For example, getting out of bed requires less bracing if the legs are moved quickly to the floor, transferring the momentum to the torso (see Fig. 16-4).

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. Education should be provided to the patient regarding expected and adverse reactions to neural gliding.

Any lingering symptom is reason to halt the stretch until the therapist can reassess the problem. Butler¹² and Shacklock²⁵ describe an excellent approach to evaluation and treatment of neural mobility.

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.^12,25 Patients with nonirritable chronic leg symptoms tend to respond well to neural mobilization. However, the patient must keep the spine stabilized while moving the leg.

Decreasing Pain and Inflammation.

Patients should use medication as directed by the physician and cold packs for about 20 minutes three or four times per day to help control pain and inflammation. Patients can be taught to alternate rest periods with periods of light activity, because sustained postures can increase swelling and pain. The therapist may apply modalities in the clinic to control pain after therapy. It is very important to minimize inflammation to decrease the risk of forming scar tissue.

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.

Minimizing Patient Fear and Apprehension.

If patients know they can control their pain level, they may be less fearful of trying activities that may cause a pain flare-up or those that have been painful in the past. They will rely less on inactivity and medication to control pain. The therapist should spend some time initially discovering the patient’s fears and alleviating those that are groundless. Greater progress will occur in the long run if the therapist initially allays patient fears and teaches the patient ways to control pain. More recent publications have pointed toward not only to the need for additional resources addressing pain and cognition but have also suggested that group meetings with other patients undergoing rehabilitation after lumbar fusion are an integral part of the healing process.13,26

Social support is suggested to help abate pain-related fear and also allow for sharing of experiences and coping strategies. 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 Patients are generally very fearful after lumbar spine surgery. Excessive anxiety and worry may cause increased muscular tension along with altered movement patterns and altered pain processing. Patients are typically afraid to move, thinking they will somehow disrupt the surgery. Patients can better tolerate flare-ups and variations in their symptoms if they expect them and have been instructed in self-management of these flare-ups. Patients are generally less apprehensive if the therapist is not apprehensive. Most people recover well and should start with that expectation. If the patient appears to be developing neuropathic pain, nerve root signs, symptoms from a new level, or any other complications, then the therapist should note the symptoms calmly and convey the information to the treating surgeon for advice without conveying anxiety to the patient.

Patient Education.

Patients who are sensitive to load bearing through the spine should take frequent short unloading rests throughout the day. Those who cannot tolerate any one position for a length of time can learn to make a circuit of their activities, frequently changing tasks (avoiding prolonged sustained postures). Patients with specific position intolerance can benefit from learning ways to avoid that position while doing daily activities. Lumbar rolls are not recommended during this phase, because most patients cannot tolerate pressure on the incision site after surgery.

Patients should understand the expected postoperative course of events, particularly concerning postoperative pain. Increasing leg pain is not a good sign, even if low back pain diminishes; conversely, decreasing leg symptoms is a good sign, even if low back pain is increasing. Less leg pain is consistent with less neurologic involvement, whereas the low back is expected to be sore because of the incision and altered facet mechanics.27 Incisional pain can be expected to decrease gradually over 6 to 8 weeks. As patients begin to return to normal activities, an associated increase in muscle soreness frequently occurs. The sooner they recondition themselves, the better they will feel. Patients should be aware that their bodies will be adapting to and remodeling from the surgery for as long as 1 to 2 years. Symptoms often shift and change during that time. The therapist should teach patients to manage flare-ups using ice, rest, and resumption of previous activities within 1 or 2 days.

Stabilization, Strength, and Reconditioning.

Different approaches have been suggested to improve the active stabilization system of the lumbopelvic region, and it is beyond this chapter to compare and contrast each. However, a more thorough program would include:

• 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. A supine progression of lower abdominal strengthening has been well outlined by Sahrmann.³²

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 load^32,33 (Fig. 16-16).

It has also been hypothesized that the deep stabilizers of the spine, such as the multifidus, also have a large proprioceptive component to the active system.³⁴ To add more proprioceptive feedback to the stabilizing system, it is integral to challenge the patient on both stable and unstable (but not unsafe) surfaces. 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. For example, before a patient performs a wall squat, they should be able to isometrically contract the inner unit and use bracing to stabilize the spine while leaning his or her back against the wall.

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. Fig. 16-23 demonstrates an ideal ending position for this stretch, which may take several months to obtain.

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

• Hip rotator stretches (Fig. 16-25)

• Latissimus dorsi stretches (Fig. 16-26)

The loss of motion caused by the spinal fusion places additional demands for motion on the adjacent segments. 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. Many different approaches to spinal mobilization exist. One can reference Maitland,³⁶ Mulligan,³⁷ and Paris³⁸ for some examples. PTs can teach patients to use two tennis balls taped together to form a fulcrum that can lie over a segment of the thoracic spine and localize motion to the segment above, thus maintaining good segmental mobility of the thoracic spine at home. This can be done in a standing or, later (when appropriate), in a semireclined position for the upper and midthoracic spine. A similar procedure can be done using a half or a full foam roll.

The hip joint is a large ball-and-socket joint with free motion in all planes. This joint can compensate for the lack of motion in the lumbar spine and should remain as flexible as possible. This can be achieved with stretching of the hip musculature. Stretching throughout phase II should be very gentle and only pushed to the point the patient can brace to prevent lumbar motion. Because these muscles attach directly to the lumbar spine or pelvis, the patient should review the principles of stretching. To stretch a muscle, one end must be fixed by something, while the other end is pulled away from the fixed end. If patients are not stabilizing the spine while stretching the hips, then they will invariably pull on the lumbar spine, jeopardizing the fusion. This may also occur at the shoulder complex. If inadequate shoulder flexion/elevation exists when a patient attempts to reach overhead, they may compensate with increased lumbar spine extension. Stretches to address glenohumeral ROM or latissimus dorsi (lats) tightness should also be included if needed. All stretching should involve stabilizing one area while pulling against it with another. For example when stretching the lats the patient should perform somewhat of a posterior pelvic tilt to avoid excessive extension of the lumbar spine (see Fig. 16-26). 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.

In addition, stretches that pull on the lumbar spine or healing soft tissues should be avoided until adequate healing has occurred. Therefore permission should be obtained from the surgeon.

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)

A callus is forming at this stage, and patients are expected to tolerate slowly increasing their activity level and returning to normal activities. 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 emphasized.

GOALS: Return to work, continue to advance/progress exercise program, practice specific skills program, initiate resistance training program (Table 16-4)

During this phase, patients may start to return to work, especially if they have sedentary jobs or occupations that do not require vigorous activity. 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.

Patients should still avoid strenuous lumbar rotation, flexion, or extension. 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.

As long as the patient is able to perform the previous stabilization exercises, they may begin a light resistance exercise program. It is not advised to do complex weight lifting tasks, but to focus on light free weight activity and machine-based 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 circuit-training 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 reassessed 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.

GOALS: Restore preinjury status, continue home program of conditioning and stabilization (Table 16-5)

During phase IV the body finishes remodeling and adapting to the changes induced during and after surgery. 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 body mechanics should be consistently demonstrated during functional tasks and patients’ understanding of these mechanics should allow them to maintain minimal strain on their back during novel situations. They should also have a good understanding of pain mechanisms, tactics to manage flare-ups, and time to contact the physician or therapist.

The bone continues to remodel and adapt to the fusion for as long as 1 year. 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). It is important to consider patient motivation at this time to help design a program that will have the most realistic chance of consistent follow-through.

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 program may require a greater focus on power, endurance, or skill, depending on the activity. Patients should work on maintaining control of a neutral spine during job- or sport-specific challenges during this phase, and the PT should obtain the clearance of the surgeon to begin working on these higher-level activities. The patient must demonstrate good trunk strength and control and good LE strength and flexibility before initiating agility drills. At this time it may also be necessary to perform a functional capacity evaluation and develop a work hardening program before returning the patient to full duty.

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. Focus should 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. Most people can manage chronic pain and maintain a high functional level despite the pain.