Yanira Vega PT, MPH; and Yadira Rivera PT
Department of Physical Medicine & Rehabilitation Manatí Medical Center, Manatí, P.R.
Corresponding Author: Yanira Vega PT, MPH, Department of Physical Medicine & Rehabilitation Manatí Medical Center, Urb. Atenas Manatí, PR 00674.
Phone: 787-621-3700 x (1483), Email: firstname.lastname@example.org
Financial Disclosure: Authors did not receive any grant or funding. None of the authors have any conflict of interest.
Physical therapy is the discipline that offers rehabilitation to patients that have an interruption of their functional status due to a variety of medical conditions. Low back pain is one of the most common problems to treat in physical therapy. In some cases, spinal surgery is considered to solve problems that compromise the integrity of the spinal cord. Lumbar Laminectomy is one of the procedures used to address these cases. Patients are unaware of what type of exercises and activities, they are allowed to perform without affecting its healing process. Medical recommendations can vary depending on each case, but literature and most studies agree that post-operative physical therapy intervention guarantees the recovery of independence of these patients. The physiotherapist will safely guide, educate and rehabilitate the patient to return to their daily functional tasks. The main objective of this work is to develop a protocol that will help educate this population about which exercises are recommended in its early post-operative stages following a Laminectomy procedure. It is important to provide patients with tools to help educate themselves even before making the decision to have a spinal surgery. The design of this protocol considers the physiotherapy and medical points of view.
The learning process of patients is an important tool to empower and initiate the building of trust needed to successfully recover from a functional dysfunction. A functional dysfunction is a term used to describe any medical problem that has disrupted the execution of daily tasks such as: studying, working, enjoying time with family or friends, and resting appropriately. For years, one of the most common conditions that urge patients to seek for physiotherapy treatment are those resulting from low back pain. Low back pain symptoms may include: localized pain in the low back area or it can irradiates to the legs and have more complications such as leg weakness and numbness, just to mention a few examples.
There are some cases in which lumbar surgery is considered in order to help the patient recover from his/her condition. It is important to stablish realistic goals and knowledge of what activities should or should not be done and exercises recommended to safely return to their optimum functional state. This action will guarantee better outcomes if done in the pre-operative phase.
There are several protocols of exercises to address these cases but the physiotherapist's expertise in coordination with the neurosurgeon and medical staff will ensure that the selected protocol is modified and tempered to the individual needs of each patient.
Patients have expressed a major concern while planning their Physical Therapy sessions following a lumbar surgery. They are usually afraid of moving and being active because they don’t know which type of exercises are recommended to begin with their rehabilitation. There are exercise protocols designed to help the patient to be active and return to daily activities missed while suffering from a low back condition.
The physiotherapy objective is to facilitate a safe exercise protocol that can be modified, regression vs. progression, to the level of performance and complexity of the affected patient. The protocol is based in those techniques and exercises that have proven to be effective in the rehabilitation of patients that have undergone a lumbar laminectomy procedure.
The expertise of the physical therapist will determine if any deviations from the protocol might be needed and adjust it to the physician’s recommendations for each specific case. There are factors that need to be taken into consideration such as: the prior level of function, general health of the patient, goals of the patient, specific medical orders after the surgery, and others. This approach will help the patient reach his/her goals in an efficient effort by integrating his daily tasks, considering safety measures and minimizing risks.
*The Cochrane study of rehabilitation following surgery for lumbar spinal stenosis* reviewed up to 2013, suggest that *active rehabilitation is more effective than usual care in improving both short and long term (back related) functional status*. They concluded that returning to normal activities and active rehabilitation produces better functional outcomes. During our practice with acute and sub-acute post operated patients, we have observed that staying active and following precautions of certain movements have helped our patients recover their freedom of movement, produces better pain relief and early return to work.
The educational process is key to empower the patient, helping them establish realistic goals of their surgery outcomes, and become more receptive and positive to the rehabilitation process. The physical therapist is the health professional that will guide the patient safely and will help optimize surgery outcomes. This process should not be focused on reacting to crisis but on delivering safe instructions and guidelines that can help the patient during their acute and subacute recovery phase from surgery.
The surgeries considered in this review will include laminectomy and minimal invasive procedures such as: discectomy, foraminotomy and microdiscectomy.
What kinds of activities can you expect to be doing on your acute rehabilitation sessions?
During the hospital stay, the patient should be consulted for Physical Therapy and Rehabilitation to perform a post-surgical evaluation of the patient and recommendations. Physical Therapist will perform an evaluation of the patient to assess his or her level of functional performance, pain, date and type of surgery and history of the condition or episode that affected the patient.
The Physical Therapist will instruct the patient:
- Safe movement and positioning while resting in bed.
- How to get up from bed to seated position and lay back down to bed.
- How to stand up, walk and transfer to another area.
- Review proper body mechanics.
- Exercise recommendations for the first 3 weeks after surgery.
Safe movement and positioning while resting in bed
- The patient should maintain the spine as straight as possible while changing positions and must be careful not to bend, twist or stoop for the first four weeks.
- The movements and activities should be done with good body mechanics and although the surgical incision is on acute healing process, movement should not be painful. The patient can experience some pain that will be managed with painkillers as needed and prescribed by the medical staff.
- In order to get upward on bed, it’s easier if the upper part of the bed is lowered. Instruct the patient to bend hips and knees to raise the buttocks and with the support of the rails, use the arms to pull up on bed. If the patient is not able to do this yet, the patient can be assisted with the draw sheet.
- The recommended resting positions during this phase are: on your side with a pillow between the legs and knees bent, or on your back with a pillow under the knees. The patient may not lie on the stomach.
How to get up from bed to seated position and lay back down to bed.
- When getting up from bed from lying down, the patient must roll on the side first.
- Then the patient will lower the legs and sit up pushing from bed with the arms.
- Once the patient is seated, the physical therapist will assess balance, tolerance, sudden pain or symptoms appearance, dizziness, fatigue or cardiovascular precautions to be considered with the patient.
- Always support the low back while seated.
- Avoid prolonged sitting. The appropriate amount of time to stay seated is 30 minutes for the first 3 weeks following surgery.
- The Physical Therapist will give assistance as needed.
How to stand up, walk and transfer to another area.
- The patient will wear appropriate shoes and the bed will be lowered to permit the patient contact with the floor. The bed brakes will be checked to be on use.
- The Physical Therapist will guide and assist the patient to standing position with support as needed from an assistive device or bed railings.
- Once the patient is standing, the Physical Therapist can instruct the patient to walk, to increase tolerance.
- The goal on the first two weeks is to reinforce standing, walking as much as the patient tolerates and practice proper body mechanics while performing typical functional activities.
Post-operative Laminectomy Protocol (From Day 1 to 3 weeks)
1. Lower abs isometrics: Lying on your back with your knees bent, press with your right hand against your right knee for 10 seconds. Repeat this action with the left side. Alternate to complete 4 - 6 times with each side. Then press with the opposite hand to complete another set, it will recruit the oblique abdominals.
3. Hips stretching (inward rotation). Lying on your back with your knees bent and your feet located hip width apart. Rotate the leg inwards bringing it closer to the other leg. You should feel a slight stretch in the lateral aspect of the hip your working. Repeat with your other leg and complete 4 - 6 times with each side.
4. Hips stretching (outward rotation). Lying on your back with your knees bent and your feet located hip width apart. Move the right leg outward and down bringing it closer to the mat or bed. Only move the leg as far as you tolerate it. Return to the starting position and repeat with the other leg to complete 4 - 6 repetitions with each side.
5. Bridging. Lie on your back with your knees bent. Find the position of neutral back that you find less painful and contract your abdominals to maintain the position, then slowly raise the hips from the surface as high as you can without losing the neutral spine position. Inhale to prepare, then exhale as you raise your hips in two counts (1 - 2), inhale at the top and then lower to the mat or bed in four counts (1 – 2 - 3 - 4) while exhaling. Repeat this exercise 4-6 times and as you get stronger and less painful raise to 10 reps.
6. Back stabilization in supine position. Lying on your back with your knees bent and neutral spine position. Raise your left arm over your head while extending the right leg for 2 seconds and return to the center of your body for 2 seconds. Inhale as your do the elongation movement and exhale as you come to the center. Make sure not to arch your back during this movement. Repeat with the other arm and leg. Complete 6 - 8 repetitions for each side. If you can’t maintain the neutral spine position, then try to perform the movement only part of the distance with your arm and leg.
7. Hamstrings stretch from seated position. Seat on a chair with both legs firmly touching the floor and neutral spine position. Extend the right leg and move the heel upward (maintain the contact with the floor). Maybe this action is enough to make you feel the stretch on the back of the leg from hip to heel. If your able lean forward from the hips as much as you tolerate maintaining your back in neutral position. Draft only as far as tolerated without feeling pain. Exhale while leaning forward on a count of 10 seconds and inhale to return to the original position. Repeat 3 times with each leg.
8.Sitting down slowly. Start standing with neutral spine. Put a chair behind you and secured it with the wall. Slowly sit down in the chair, in an interval of 10 - 12 seconds. As soon as you touch the seat with your buttocks, immediately return to the standing position. Then begin sitting again. Repeat 10 times.
9. Balance on one leg. After finding a position where the back is in neutral and contracting the abdominals, seek to maintain balance on one foot, you can keep the elevated leg touching the floor slightly with the tip of the foot. You can use support with your hands if needed. Maybe this action is enough to begin with unilateral balance but you can add the next challenge if this it does not reproduce you pain. Once you tolerate unilateral balance, begin to move your weight from the heel to the ball of the foot and back again. Keep all the foot on the floor during this transfer of weight which should be light. Repeat 10 times with each side. Once completed rest and then try to perform the activity but by transferring the weight from the inside to the outside of the foot and repeat 10 times with each side
10. Walking. You can walk as much as you tolerate. Maybe an assistive device might be needed. The considerations you must be aware at all times are:
- Wear comfortable and safe shoes.
- Wait a few minutes while doing transitions, for example: when getting up from lying position to seated or from a seated position to a standing position just to make sure you don’t get dizzy or that other symptoms bother you.
- Make sure the brakes are on while using the hospital bed or a wheelchair.
Post-operative Laminectomy Protocol (From week 4 to 8 weeks)
The exercise program from the first 3 weeks can be done or combined with this exercise protocol. The Physical Therapist can assess and guide the patient to either regress or progress the exercises in a safe and individually manner. This exercises can be done on a mat.
- Reverse curl. Starting position is lying on your back with the feet on the ground. Contract the abdominals and keep your back on a neutral position. Maintaining a 90 degree angle on your knee, lift that foot from the floor until you reach 90 degrees of hip flexion. Put that leg back on the floor and repeat 6 times with each side. Inhale as you go up and exhale while going back down. You can do this exercise in several ways:
- one set of 6 repetitions for each leg
- one set of 6 repetitions alternating legs
- one set of 6 repetitions lifting both knees toward the chest, and slowly lowering them to the floor. It is very important that you don’t lose the neutral spine position (don’t arch your back).
Hamstrings stretch. Lying on the mat on your back, bend your knee toward your chest and hold your thigh with your hands. Slowly extend the knee as much as you can tolerate. Hold the stretch for 10 seconds. Take a break. Repeat and hold for 15 seconds and after a second rest, repeat and hold for 30 seconds. Repeat this exercise with the other leg.
3. Piriformis stretch. Lying on mat on your back with your knees bent, cross one leg over the knee of the opposite leg. Contract your abdominals and lift both legs toward your chest while you exhale. Hold the stretch for 10 seconds. Take a break. Inhale and slowly lower legs. Repeat 3 times with each leg.
4. Core settings on prone. Starting position is prone on mat weight bearing on forearms and knees. Press in your forearms and lift your hips a few inches of the floor for 10 seconds. Tighten your ABS so that you do not arch your back. You can do 12 – 15 repetitions.
5. Cat and camel. Starting position is on quadruped position on the mat. Inhale to prepare, then exhale as you arch your back and lower your head, contracting your abdominals. Then inhale and allow your back to move in the direction of the floor while lifting his head. Don’t bend your elbows at any time. The movements should be slow and with a pause at the end in each direction and allow yourself to move vertebrae by vertebrae and as comfortable as you can. Repeat 6 – 8 times.
6. Spine Stabilization on quadruped. Starting position is on quadruped position on the mat. Find your neutral spine position and maintain your neck long as if you were looking at a mirror located on the floor.
- Arms: Exhale while you raise and elongate your arm to draw a line with your torso maintain the pose for 2 seconds and then back to the floor. Repeat this action with your other arm and alternate to complete 5 repetitions with each arm
- Legs: Exhale while you raise and elongate your leg and level it with your torso maintaining the pose for 2 seconds and then back to the floor. Repeat this action with your other leg and alternate to complete 5 repetitions with each leg.
- Arms and legs (opposite sides): Exhale while you raise and elongate your right arm and left leg and level them with your center. Maintain the pose for 2 seconds and then lower them back to the floor. Repeat this action with the other side and alternate to complete 5 repetitions with each side.This exercise can be modified by using a chair or Swiss ball for support on your stomach or if you have wrist or knee problems.
7. Hip hike. This exercise will be done by those patients that are capable of unilateral stance without losing balance. Do 10 mini squats on the supporting leg and then elevate the other leg upward 10 times. Repeat with the other leg.
8. Cardiovascular training. Walking as much as the patient tolerates can be progress from 20 minutes/day to 60 minutes/day. The patient can also use a stationary bicycle, if it doesn’t reproduce symptoms and progress from 10 minutes/day up to 30 minutes/day.
Patients with spinal disorders that have had spinal surgeries must stay active to guarantee their success in achieving their functional outcomes. Exercise is one of the most commonly used interventions for the management of spinal disorders
. The education of the patient is the key to a more satisfied and better informed patient.
Cameron MH, Monroe LG. Physical Rehabilitation Evidence-based examination, evaluation, and intervention. Saunders 2007 (2, 140, 178).
Mc Farland C, Burkhart D. Rehabilitation protocols for surgical and nonsurgical procedures Lumbar Spine. North Atlantic Books 1999.
Mc Gregor AH, Burton AK, Sell P, Waddell G. The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression. Eur Spine Journal 2007 Mar 16(3): 339-346.
Mc Gregor AH, Probyn K, Cro S, Doré CJ. Burton AK, Balagué F, Pincus T, Fairbank J. Rehabilitation following surgery for lumbar spinal stenosis. Cochrane Database Syst Rev 2013.
Waddell G, Sell P, McGregor A, Burton K. Your back operation. The stationary office. 2005.