Pilates for Lumbar Spinal Fusion: Recommended Conditioning for Multilevel Spinal Fusion Rehab

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1 Pilates for Lumbar Spinal Fusion: Recommended Conditioning for Multilevel Spinal Fusion Rehab Maggie Curcio October 14, 2012 Summer Chicago 1

2 Abstract This paper focuses on a suggested rehabilitative and ongoing conditioning program for first twelve months for patients who have undergone single or multilevel lumbar spinal fusion surgeries. Since 1996, the number of spinal fusion surgeries in the United States has increased as much as 116% and has become one of the most increased of orthopedic surgeries over the past fifteen years (Take Care of Your Health After Spinal Fusion, 2011). However, while spinal fusion may relieve a patient of acute pain, underlying issues (poor posture, sacroiliac joint instability, weak abdominal or back extensor muscles, and limited hip or thoracic rotational movement) still persist and can cause long term pain if not treated properly. The focus of this paper will include suggested post-operative conditioning during the first 90 days as well as during 3-6, 6-9, and 9-12 months and beyond. Many of these recommendations can be instituted with patients as a preventative measure as well. 2

3 Table of Contents 1. Anatomical Description and Spondylolithesis 2. Case Overview Months Post-Surgery: Physical Therapy Month Conditioning Recommendations 5. Conclusion 3

4 Anatomical Description of the Lumbar Spine The human spine is made up of 33 vertebrae including 7 cervical, 12 thoracic, 5 lumbar and 3-5 sacral and 4 coccygeal as well as of bony elements, flexible ligaments, tendons, muscles, and nerves (Isacowitz, 2008). In between these vertebrae are 23 intervertebral discs which act as a cushion to provide to allow slight movement of the vertebrae and acts as a ligament to hold the vertebrae together (sacral and coccygeal segments of the spine do not consist of intervertebral discs as they are naturally fused segments). (Wikipedia, 2012). In addition, the lumbar spine is designed to be incredibly strong to protect the highly sensitive spinal cord and spinal nerve roots while remaining flexible to provide for mobility in many different planes (including flexion, extension, lateral, and rotation). An image depicting the spine (with focus on the lumbar region) is below. Spondylolithesis A back condition that is common to the lumbar spine is called spondylolisthesis which occurs when one vertebra slips forward on the adjacent vertebrae. This will produce both a gradual deformity of the lower spine as well as a narrowing of the vertebral canal (Barr KP, 2005). Spondylolisthesis is graded according to the amount that one vertebral body has slipped forward on another. A grade I slip means that the upper vertebra has slipped forward less than 25 percent of the total width of the 4

5 vertebral body, a grade II slip is between 25 and 50 percent, a grade III slip between 50 and 75 percent, a grade IV slip is more than 75 percent, and in the case of a grade V slip, the upper vertebral body has slid all the way forward off the front of the lower vertebral body (Take Care of Your Health After Spinal Fusion, 2011). Spondylolisthesis with the slippage greater than 50 percent of the width of the adjacent vertebral body generally requires a spinal fusion to stop further slippage and provide relief from the associated symptoms of instability and nerve root irritation (Parker SL, 2012). Causes of spondylolithesis typically include injuries or congenital defects that progress over time. Many patients with spondylolisthesis will have vague symptoms and very little visible deformity. Often, the first physical sign of spondylolisthesis is tightness of the hamstring muscles in the legs. Only when the slip reaches more than 50 percent of the width of the vertebral body will there begin to be a visible deformity of the spine and often there may be a dimple at the site of the abnormality. Sometimes there are mild muscle spasms and usually some local tenderness can be felt in the area. Range of motion is often not affected, but some pain can be expected. In a recent study conducted on patients with degenerative lumbar spondylolithesis, nearly 54% of patients eventually required surgical management due to lack of improvement (pain, disability, quality of life, depression, general health not improved over a 2-year period). Additionally, costs were estimated at nearly $10,000 USD without improvement for comprehensive medical management during a two-year period (Parker SL, 2012). Case Overview Patient was a 37 year old female suffering from lumbar general disk disease, degenerative isthmic spondylolisthesis at the L4 (Grade II), and subsequent bilateral lumbar radiculopathy. She had extensive conservative care without improvement including physical therapy, chiropractic care, attempted facet joint injections, and pain medication. Posterior spinal fusion at the L3-L5 was recommended as next course of action. During the course of her surgery, the L5-S1 disk space was evaluated and was noted to be severely vertical and it was determined at this point to include this level in 5

6 the fusion in order to allow for better stability and reduction in the spondylolisthesis segment. Immediate post-surgical treatment (48 hours post-surgery) included sitting, standing, short walks and practice of daily activities (e.g. getting in and out of a car, stairs, laying down and getting up, etc.). Patient was instructed to restrict all activities beyond this for first two weeks post operation. Upon clearance at two weeks, patient was instructed to increase daily walking activity to minutes per day and sitting up to minutes per day. At 6-8 weeks post-surgery, the patient was instructed to begin physical therapy and at 12 weeks post-surgery the patient was cleared for select lowimpact exercise (e.g. walking, elliptical) as well as light weight-bearing exercise (under 10 lbs.). The initial goal of a physical therapy program was to increase spinal and trunk stability. Since spinal stability consists of three key areas: bone and ligamentous structures, muscular systems that surround the spine, and neural control system that coordinates muscle activity, endurance of the muscular systems was more important than the muscle strength (Barr KP, 2005). A focus on key back muscles including spinal extensors, trunk flexors and pelvic stabilizers was the initial focus on the therapy. Once muscular stability and endurance was increased, the focus shifted to increasing mobility (particularly in the thoracic region) and strength (particularly in the pelvic, trunk and back muscle systems). Given that the spine was essentially now fused from L3 downward (as sacral and coccygeal vertebrae are already naturally fused), mobility of the lower spine was extremely limited and care was given to determining a program that was sustainable and allowed for increased strength and mobility in the non-fused sections of the spine as they would be susceptible to increased risk of disc and spinal conditions in the future. 2-3 Months Post-Surgery: Physical Therapy Initial physical therapy included gentle stretching and basic pelvic and trunk stabilization exercises. Flexion, extension and rotational exercises of the back and trunk were restricted. In addition, extra focus was given to hip extensor (particularly 6

7 hamstrings) and dorsal flexor (calf) stretching as muscles were extremely tight. The following exercises were used 3-4 times per week. 1. Abdominals/Pelvic Stabilization: a. Abdominal Contraction: Lying in prone position with knees bent, contract abdominals and squeeze ribs down. Hold for 5 seconds. Relax and repeat 10 times. b. Supine Posterior Tilt: including contraction of Kegal muscles to increase pelvic stabilization. This increased to small pelvic curls as patient gained strength back. 2. Calf Stretch: Standing on calf stretch apparatus or stair, dorsi flex foot while keeping other foot straight. Increased to standing on flat surface and conducting as heel raise. 3. Hip Extensors: a. Hamstring Stretch with resistance band: Lying prone with one knee bent and one foot dorsi flexed in resistance band. Slowly straighten knee into perpendicular position to increase stretch. Hold for 20 seconds, relax and repeat 5 times on each side. b. Piriformis Stretch: Lie on back with both knees bent. Cross one leg on top of the other. Pull opposite knee to chest until a stretch is felt in the buttock/hip area. Hold 20 seconds. Relax. Repeat 5 times each side. 4. Hip Adductors: a. With resistance band around both feet, walk sideways in small steps until resistance is felt. Continue for 5-7 minutes on each side to increase hip adductor strength and stability. b. Clam: Lie on one side with lower arm bent under head and upper arm resting with hand on floor near chest. Bend both knees and flex hips to approximately 45 degrees and find neutral spine position. Slowly raise upper leg 8 to 10 inches and lower while keeping heels together. Do 5 to 10 repetitions and repeat on opposite side. 5. Balance/Trunk Stability: 7

8 a. Wobble Board: Stand on wobble board with support for 30 second increments. b. Pilates Ball: Sit on Pilates ball with therapist gently pushing side to side Month: Conditioning Recommendations 3-6 Month Post Surgery: Additional Physical Therapy and Light Exercise After 3 months, the patient was cleared for low-impact aerobic exercise for longer periods (e.g minutes of brisk walking, elliptical machine, etc.). Biking, swimming, running or any high-impact activities were still restricted until the six month mark. Additional physical therapy, seated massage, and/or fundamental-level Pilates were recommended with restrictions still around flexion/extension and spinal articulation of any sort. From a BASI Block System perspective, I would recommend beginner exercises (based on strength of patient) with a focus on trunk and pelvic lumbar stability Months After a patient has demonstrated improvement in both pelvic lumbar stability as well as increased strength in abdominals, back extensors, and hip flexors, I would recommend increasing the challenge of both mat and equipment to include additional intermediate level exercises. Focus should continue on building pelvic stabilization as well as on increasing flexibility of both hip flexors/extensors, gaining more spinal and thoracic mobility, and advancing to more challenges range of motion exercises. 12 Months + After one year and doctor clearance, patients should be allowed to take on more challenging and advanced Pilates repertoire based on their own strength and capability. Care should still be given to spinal articulation exercises and anything that may create contraindication for the lower lumbar spine. In addition, movement and exercises that increase thoracic mobility should be a key factor in the design of any program. Regular inclusion of the Step Barrel as well as thoracic stretch and spinal mobility exercises should be considered. 8

9 Recommended Pilates Mat and Auxiliary Workouts 9

10 Recommended Pilates Equipment Program (3-12 Months) 10

11 Additional Thoughts Depending upon the nature of the fusion and the ability of the patient, I would recommend avoiding most spinal articulation exercises until at least a year postsurgery. In some cases, spinal articulation exercises may need to be permanently avoided especially in multi-level fusion surgeries as they will be contraindicated for patients. Additionally, I would recommend avoiding exercises with deep lumbar flexion (e.g. Push Through Series such as Sitting Forward, Sitting Back, etc. on Cadillac, Monkey on Cadillac, Rowing Series, Climb a Tree and Teaser on Reformer, etc.) as these will likely be too difficult if not impossible for a client to achieve. Some spinal articulation exercises may be introduced after a 12-month period with assists or modification (e.g. Teaser on Cadillac with ball, Neck Pull with cushion, Tower on Cadillac, etc.); however, these should be done with great care and consideration of client s abilities. Conclusion Research shows that people suffering from lower back pain have deficits in spinal proprioception and will make repositioning errors while trying to stay in neutral spine. There is no correlation with improved proprioception or posture control postsurgery and in some studies, most people will need more extensive training in posture and exercise positioning because their ability to reproduce precise movements reliably is reduced (Barr KP, 2005). As a result, spinal fusion rehabilitative care can benefit greatly from inclusion of an ongoing, lifetime Pilates conditioning program as it will help to extend and improve upon movement, mobility, balance, ROM and strength learned in physical therapy 11

12 References 1. Team Pilates Pilates Consult blog Specific Exercises for Scoliosis and a Spinal Fusion (Angelie Meizer) November 14, Pilates for Fragile Backs Recovering strength after surgery, injury, or other back problems (Pilates for Fragile Backs) 3. Comprehensive Medical Management of Lumbar Stenosis and Spondylolithesis is not Effective in Real-World Care: A Value Analysis of Cost, Pain, Disability and Quality of Life. Neurosurgery August; 71(2):e Authors: Parkers SL, Zuckerman S, Shau D, Mendenhal S, Godil SS, McGirt M. 4. Lumbar Stabilization Core Concepts and Literature, Part I. American Journal of Physical Medicine & Rehabilitation. 2005;84: Authors: Barr KP, Griggs M, Cadby T. 5. Study Guide Comprehensive Program. Body Arts and Science International Author: Rael Isacowitz. 12