Post-Surgical Lumbar Discetomy lisa dietzel december 5, 2006 9/2006 costa mesa
Abstract Back Pain is one to the most common ailments known to man. More than 80% of today s population will experience some sort of back pain in their lifetime. As discs begin to gradually degenerate, which happens in all adults around the age of 30, a gradual bulging of the discs can occur. A bulging disc usually is not painful under normal conditions. Our discs are designed to slightly bulge during normal activities. This allows our spine to absorb the tremendous forces we expose it to everyday. However, if a disc develops a tear and the inner nucleus pushes through to the spinal nerves, surgery may be a consideration. Lumbar Discectomy surgery has significantly improved in recent years and is a very common and successful treatment to relieve the pain. Page 2
Table of Contents Abstract 2 Table of Contents 3 Herniated Disc 4 Lumbar Discectomy 6 Case Study 7 Conditioning Program 8 Conclusion 12 Bibliography 13 Page 3
Herniated Disc A common cause of low back and leg pain is a herniated disc. Discs are defined as the soft cushions between the bones of the spine. The spine is made up of a series of connected bones called vertebrae. The disc is a combination of strong connective tissues that hold one vertebrae to the next, and acts as a cushion between the vertebrae. A healthy disc provides a shock absorbing quality and is quite spongy. The disc is made up of a tough outer layer called the annulus fibrosis and a gel-like center called the nucleus pulposus. A herniated disc is a displaced fragment of nucleus that is pushed through a tear in the outer layer of the disc. The weak spot in the disc is directly under the nerve root, and a herniated disc in this area puts direct pressure on the nerve. When part of a disc presses on a nerve in the lumbar region, it can cause pain in both the back and the legs. The size of the disc herniation varies from person to person. The average person will begin to feel discomfort when the herniated disc measures 3mm. At 4mm to 5mm a person may begin to feel pain and symptoms of sciatica. How bad the pain is depends on how much of the disc is pressing on the nerve. Page 4
Approximately 90% of disc herniations will occur at L4-L5 or L5-S1, which causes pain in the L5 nerve or S1 nerve. The majority of people who suffer from disc herniation do not require surgical treatment. The goals of non-surgical treatment are to reduce the irritation of the nerve and disc. Some first treatments include therapies such as ultrasound, electric stimulation, hot packs, cold packs, physical therapy, traction, anti-inflammatory medications, exercise, epidural steroid injections and short period rest. Most people suffering from a herniated disc can recover in about four weeks. If a person continues to experience pain or numbness after four to six weeks, they should consult their doctor. Surgery may be needed to relieve the pain. Page 5
Lumbar Discectomy A Discectomy is removing the soft gel-like material that has extruded out of the disc into the neural canal. Lumbar Discectomy surgery is usually recommended only when specific conditions are met: Leg pain limits normal daily activities Weakness in legs and or feet Numbness Impaired bowel and or bladder function Postoperative care for lumber Discectomy surgery has significantly improved in the recent years. It is a much shorter recovery period, less pain, and a higher success rate. Early mobilization may actually help patients heal sooner, through the area around the disc covering has a poor blood supply and healing around the inner core of the disc may take three to four month to heal over. It is usually recommended to begin a physical therapy program between two and three weeks after surgery, involving stretching, back and core strengthening exercises. The safest way to stretch is in the supine position because your back is fully supported. It is generally advised to do stretching exercises frequently and gently. The exercises should be done 5 to 6 times a day for 6 to 12 weeks. Page 6
Case Study Jill has always thought of herself as a healthy active person. She grew up a typical Southern California girl who enjoyed many outdoor activities such as running, skateboarding, surfing and snowboarding. Today she is a 45-year-old woman who feels her life has been given back to her. Almost 10 months ago Jill underwent a Lumber Discectomy after an MRI revealed she had four herniated discs. Two of the herniations are considered minor; under 4mm each but the other two were very extreme measuring 12mm and 15mm. Jill described her pain initially to be a dull buzzing feeling in her bones. She often experienced muscle cramping, spasms and weakness, sharp shooting pains, dull constant pains, numbness, tingling and bowel impairment. For the first time in over 10 years, Jill is living pain free. After four months of physical therapy and six months of Pilates, Jill has gone from unable to touch her toes to completing the Body Arts and Science International Comprehensive Teacher Training Program. Her journey as a Pilates professional has just begun and she hasn t felt more alive, aware or creative in years. As life s challenges have inspired her, life s possibilities continue to encourage her. Page 7
Conditioning Progam BASI Approach Block System WEEK 1-4 WEEK 5-8 Limited Range of Motion for first 4 weeks light to no resistance of weight no extension, no lateral flexion, no rotation Mat Work Basic Warm Up No rotation Pelvic Tilt Pelvic Curl Chest Lift Single Leg Lifts Squats w/ball against wall Swimming w/ball Reformer Footwork /light springs No No Hip Work No Spinal Articulation Stretches Standing Lunge No Full Body No Arm Work No Additional Leg Work Add resistance, stretching, minimal rotation, no extension, no lateral flexion Mat Work Basic Warm Up Spine Twist Supine Hamstring Stretch w/theraband Spine Stretch Chest Lift w/rotation Hundreds Prep Hundreds /bent knees Cat Stretch Shoulder Bridge Prep Reformer Footwork /add resistance Hundreds Prep Hip Work Basic /limited ROM No Spinal Articulation Stretches Scooter Round Back Flat Back Arm Work Supine Arm Series No Additional Leg Work Page 8
Add resistance, stretching, minimal extension, minimal lateral flexion Mat Work Basic Warm Up Single Leg Stretch Criss Cross Side Lifts Back Extension WEEK 9-12 WEEK 13-16 Reformer Footwork Hundreds Prep Hundreds /bent knees Hip Work No Spinal Articulation Stretches Up Stretch Elephant Reverse Knee Stretch Arm Work Supine No Additional Leg Work Continue to add stretching and resistance Mat Work Intermediate Warm Up Leg Circles Roll Up Hamstring Pull 1 Roll-Like-A-Ball Double Leg Stretch Spine Twist Side Kick Single Leg Kick /modified with forehead down on back of palms Reformer Footwork Coordination Round Back Flat Back Tilt Twist Hip Work Basic Series No Spinal Articulation Stretches Stomach Massage Series Arm Work Sitting Series Shoulder Push Shoulder Push Single Arm No Additional Leg Work Cadillac Footwork /light resistance Roll Up w/rub Mini Roll Ups Mini Roll Ups Oblique Hip Work - Basic Leg Springs No Spinal Articulation No Stretches Sitting Forward Side Reach Arm Work Arms Standing Series /no Butterfly Shoulder Adduction Sitting Side Shoulder Adduction Sit Forward Scapula Glide Additional Leg Work Squats Page 9
WEEK 17-20 Continue to add to the repertoire. No spinal articulation with any added resistance, no lateral flexion with added resistance, no back extension with added resistance. Mat Work Intermediate Warm up Saw Front Support Seal Puppy Swimming Reformer Footwork Hip Work Intermediate Spinal Articulation Bottom Lift Bottom Lift w/extension Stretches Kneeling Lunge Up Stretch 2 Long Stretch Arm Work Additional Leg Work Single Leg Skating Lateral Flexion/Rotation Side Over on Box Back Extension Breaststroke Prep Cadillac Footwork /light resistance Roll Up Top Loaded Bottom Lift w/rub Hip Work Single Leg Supine No Spinal Articulation Stretches Shoulder Stretch Kneeling Cat Stretch Arm Work Additional Leg Work Wunda Chair Footwork /light resistance Standing Pike Reverse Standing Pike Spinal Articulation Pelvic Curl Arm Work Shrugs Triceps Press Sit Additional Leg Work Leg Press Standing Hamstring Curl Hip Opener Page 10
WEEK 21-24 Continue to add to the repertoire. Mat Work Intermediate Warm up Corkscrew Back Support Reformer Footwork Teaser Prep Hip Work -Intermediate Spinal Articulation Stretches Full Lunge Side Split Arm Work Kneeling Rowing Back 1 Rowing Back 2 Rowing Front 1 Rowing Front 2 Additional Leg Work Hamstring Curl Lateral Flexion/Rotation Mermaid Back Extension Breaststroke Pulling Straps 1 Pulling Straps 2 Cadillac Footwork Breathing w/ptb Hip Work Spinal Articulation Stretches Thigh Stretch Sitting Back Arm Work Additional Leg Work Single Leg Side Series Lateral Flexion/Rotation Side Lift w/ptb Back Extension Prone 1 Prone 2 Wunda Chair Footwork /add resistance Cat Stretch Sitting Pike Full Pike Spinal Articulation Arm Work Triceps Prone Frog Back Side Kneeling Arm Additional Leg Work Frog Front Lateral Flexion/Rotation Side Pike Side Stretch Side Kneeling Stretch Back Extension Basic 1 Swan Swan on Floor Back Extension Single Arm Page 11
Conclusion The previous repertoire is a six month program designed to continue the rehabilitation of a successful Lumbar Discectomy. Jill has been given full clearance from her and Physical Therapist to continue her rehabilitation. A few modifications will need to be to exercises for the next 18 to 24 months. The first four weeks it is recommended to limit the ROM, no lumbar extension, no lateral flexion and no rotation. After the third month minimal extension, lateral flexion and rotation can be added with light resistance. Spinal articulation with any resistance should be avoided for the first two years to allow for complete healing and to avoid any additional injury. In my opinion, Pilates is an excellent form of physical therapy for post-surgical Lumbar Discectomy patients. It is recommended to begin with early mobilization, stretching exercises, strengthening and conditioning exercises and a return to normal activity. The Pilates approach combines the training of the mind and body to achieve strength through a system that is designed to continually develop, challenge and increase body awareness. Page 12
Bibliography BOOK Rael Isacowitz Study Guide: Comprehensive Course Movement Analysis - Mat Work - Reformer - Cadillac - Wunda Chair and Ladder Barrel - Auxiliary Equipment 2002-2004 - Body Arts and Science International Blandine Calais - Germain Anatomy of Movement 1993 WEBSITE www.esurgeon.com - What is a Herniated Disc Dr. Sylvain Palmer, M.D., F.A.C.S. Neurological Surgery December 2006 www.back.com - Chronic Pain Therapies December 2006 www.spineuniverse.com - Lumbar Disc - Anatomy December 2006 Page 13