1 Pilates for Lumbar Spinal Fusion: Recommended Conditioning for Multilevel Spinal Fusion Rehab Maggie Curcio October 14, 2012 Summer 2012 - Chicago
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Pilates for Lumbar Spinal Fusion:
Recommended Conditioning for Multilevel Spinal Fusion Rehab
Maggie Curcio
October 14, 2012
Summer 2012 - Chicago
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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.
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Table of Contents
1. Anatomical Description and Spondylolithesis
2. Case Overview
3. 2-3 Months Post-Surgery: Physical Therapy
4. 3-12 Month Conditioning Recommendations
5. Conclusion
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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
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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
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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 20-30 minutes per day and sitting up
to 60-90 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 low-
impact 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
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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:
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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.
3-12 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. 30-60 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.
6 -12 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.
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Recommended Pilates Mat and Auxiliary Workouts
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Recommended Pilates Equipment Program (3-12 Months)
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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 post-
surgery. 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 post-
surgery 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
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References
1. Team Pilates – Pilates Consult blog “Specific Exercises for Scoliosis and a
Spinal Fusion” (Angelie Meizer) November 14, 2010
2. 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. 2012 August; 71(2):e554-5. 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;84:473-480. Authors: Barr KP, Griggs
M, Cadby T.
5. Study Guide – Comprehensive Program. Body Arts and Science International.
2008. Author: Rael Isacowitz.