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How	
  to	
  Manage	
  
	
  
Non-­‐opera/ve	
  and	
  Opera/ve	
  
BACK	
  REHABILITATION	
  
Stephen	
  Boyd	
  -­‐	
  Physiotherapist	
  
REHABILITATION	
  PRINCIPLE	
  
•  Assess	
  any	
  Abnormality	
  and	
  treat	
  to	
  correct	
  
the	
  Abnormality	
  
SEVERE	
  LOW	
  BACK	
  PAIN	
  
•  AIM	
  TO	
  REDUCE	
  PAIN	
  AND	
  INFLAMMATION	
  
•  COMFORT	
  POSITONS	
  –	
  NEUTRAL	
  SPINE	
  
•  ENCOURAGE	
  MOVEMENT	
  THAT	
  RELIEVES	
  
•  BED	
  REST<48HRS	
  
•  +/-­‐	
  TAPING	
  
•  ANALGESIA	
  /NSAIDS	
  
•  LOCAL	
  MODALITIES	
  FOR	
  PAIN/SPASM	
  (	
  HEAT,	
  ICE	
  ,	
  ELECTRO,	
  MANUAL	
  
TH.)	
  
•  EXERCISE	
  AWAY	
  FROM	
  AGGRAVATION	
  
•  WATCH	
  FOR	
  NEURAL	
  SIGNS	
  
SUB-­‐ACUTE	
  LOW	
  BACK	
  PAIN	
  
	
  
OFTEN	
  WITH	
  ASSOC.	
  MUSCLE	
  SPASM	
  /	
  IRRITATION,	
  INCREASED	
  NEURAL	
  
TENSION	
  
HYPOMOBILE	
  SEGMENTS	
  –UTILISE	
  MANUAL	
  THERAPY	
  
	
  
	
  
•  POOR	
  POSTURES,	
  BIOMECHANICS	
  
•  REDUCE	
  PAIN	
  /	
  INFLAMMATION	
  
•  RESTORE	
  ROM	
  (	
  MANUAL	
  THERAPY,	
  EXERCISE)	
  
•  FLEXIBILITY	
  AND	
  STRENGTH	
  
•  CARDIO	
  FITNESS	
  
•  EDUCATION	
  	
  
REHABILITATION	
  AFTER	
  BACK	
  
PAIN	
  EPISODE	
  
•  MODIFY	
  ACTIVITIES	
  
•  CORRECT	
  BIOMECHANICAL	
  ABNORMALITIES	
  
•  POSTURAL	
  ASSESSMENT	
  OF	
  FUNCTIONAL	
  POSITIONS	
  
•  LIFTING	
  MECHANICS	
  
•  CORE	
  STABILITY	
  :	
  LOCAL	
  THEN	
  GLOBAL	
  
•  ASSESS	
  /	
  STRETCH	
  TIGHTNESS	
  
•  EDUCATION	
  
•  HOME	
  EXERCISE	
  REGIME	
  
ehR	
  
REFERRAL	
  	
  PRESCRIPTIONS	
  
Acute	
  Back	
  Pain	
  
	
  Local	
  modali/es	
  for	
  pain/spasm	
  
	
  Encourage	
  non-­‐aggrava/ng	
  movement	
  and	
  exercise	
  
	
  Educate	
  /	
  encourage	
  neutral	
  spine	
  
	
  Manual	
  therapy	
  techniques	
  
	
  Home	
  exercise	
  	
  
	
  Back	
  Care	
  advice	
  	
  
	
  
RehR	
  
REFERRAL	
  PRESCRIPTIONS	
  
SUB-­‐ACUTE	
  BACK	
  PAIN	
  
	
  Local	
  modali/es	
  for	
  pain/spasm/hypo	
  mobility	
  
	
  Restore	
  range	
  with	
  manual	
  therapy	
  and	
  exercise	
  
	
  Core	
  stability	
  regime	
  and	
  upgrade	
  
	
  Review	
  postures/biomechanics	
  
	
  Home	
  exercise	
  /	
  Cardio	
  fitness	
  
	
  
	
  
	
  
CHRONIC	
  DISEASE	
  MANAGEMENT	
  PLAN	
  
FUNCTIONAL	
  STABILITY	
  
	
  
	
  
	
  
NEED	
  TO	
  UTILISE	
  BOTH	
  MUSCLE	
  FORCES	
  AND	
  PASSIVE	
  STRUCTURES	
  TO	
  
DYNAMICALLY	
  STABILISE	
  THE	
  SPINE	
  FUNCTIONALLY	
  
	
  
ANY	
  DEFICITS	
  ASSESSED	
  NEED	
  TO	
  BE	
  ADDRESSED	
  IN	
  A	
  REHAB.	
  PLAN	
  
CORE	
  STABILITY	
  
	
  
•  MUSCULAR	
  CONTROL	
  TO	
  MAINTAIN	
  FUNCTIONAL	
  STABILITY	
  
•  MUSCULAR	
  CORSET	
  
•  STABILITY	
  INVOLVES	
  PASSIVE	
  AND	
  ACTIVE	
  STIFFNESS	
  
•  INSTABILITY	
  WHEN	
  EITHER	
  COMPONENT	
  DISTURBED	
  
CORE	
  STABILITY	
  
•  GLOBAL	
  :	
  DYNAMIC	
  /	
  PHASIC	
  MUSCLES	
  =	
  ACTIVE	
  TRUNK	
  MOVEMENT	
  
•  RECTUS	
  ABDOMINIS	
  
•  EXTERNAL	
  OBLIQUES	
  
•  ILIOCOSTALIS	
  (THORACIC	
  PART)	
  
•  LATISSIMUS	
  DORSI	
  
•  LINK	
  PELVIS	
  TO	
  THORACIC	
  CAGE	
  
CORE	
  STABILITY	
  
•  LOCAL	
  :	
  POSTURAL	
  /	
  TONIC	
  =	
  INTERSEGMENTAL	
  STABILITY	
  
•  TRANSVERSUS	
  ABDOMINIS	
  
•  MULTIFIDIS	
  
•  PSOAS	
  MAJOR	
  
•  QUADRATUS	
  LUMBORUM	
  
•  DIAPHRAGM	
  
•  ILIOCOSTALIS	
  (	
  LUMBAR	
  SEGMENT)	
  
•  INTERNAL	
  OBLIQUE	
  
STABILITY	
  TEACHING/
RETRAINING	
  
•  EDUCATION	
  :	
  ANATOMY	
  AND	
  FUNCTION	
  
•  ISOLATE	
  DEEP	
  LAYER	
  T.A	
  
•  MOTOR	
  RELEARNING	
  
•  TRAIN	
  STABILISERS	
  IN	
  ISOLATION	
  
•  ADD	
  FUNCTIONAL	
  MOVEMENTS	
  WITH	
  STABILITY	
  
•  PAINFREE	
  	
  
•  NEUTRAL	
  SPINE	
  INITIALLY	
  
•  FEEDBACK	
  :	
  TACTILE	
  ,	
  PBU,	
  ULTRASOUND	
  
STABILISATION	
  EXERCISES	
  
•  INITIATE	
  PELVIC	
  FLOOR	
  	
  HELPS	
  ISOLATE	
  T.A.	
  
•  PALPATE	
  1CM	
  IN	
  1CM	
  DOWN	
  A.S.I.S.	
  
•  FEEL	
  TENSION,	
  NOT	
  BULGE	
  
•  CONTROLLED	
  BREATHING	
  
•  SUPINE	
  /	
  4	
  POINT	
  KNEEL	
  /	
  STANDING	
  /	
  SITTING	
  
STABILISATION	
  EXERCISES	
  
•  ISOMETRIC	
  ABDOMINALS	
  IN	
  
SUPINE	
  
•  SIDE	
  LYING	
  +	
  GLUTEUS	
  
MEDIUS	
  
•  SUPINE	
  BRIDGE	
  
•  ABDOMINAL	
  CURL	
  
•  4	
  PT	
  KNEEL	
  
•  PRONE	
  PLANK	
  
•  SIDE	
  PLANK	
  
•  STANDING	
  LUNGES	
  
•  STEP	
  UPS	
  
•  GYM	
  BALL	
  SEATED	
  	
  
•  GYM	
  BALL	
  LIFTING	
  
•  BALANCE	
  DISC	
  
	
  
STRETCHING	
  
•  LUMBAR	
  ROTATION	
  
•  LUMBAR	
  FLEXION	
  
•  HIP	
  FLEXION	
  
•  HIP	
  EXTENSION	
  
•  HIP	
  ADDUCTION	
  
•  STRAIGHT	
  LEG	
  RAISE	
  
•  DEEP	
  HIP	
  ROTATORS	
  
•  THORACO-­‐LUMBAR	
  ROTATION	
  
•  LUMBAR	
  EXTENSION	
  
POST-­‐OPERATIVE	
  
REHABILITATION	
  
•  UNDERSTANDING	
  THE	
  SURGERY	
  
•  REALISTIC	
  GOALS	
  /	
  TIMELINES	
  
•  PAIN	
  CONTROL	
  
•  EARLY	
  EXERCISE	
  
•  EARLY	
  MOBILITY	
  
•  DISCHARGE	
  WITH	
  REHABILITATION	
  PACKAGE	
  
POST-­‐OPERATIVE	
  EXERCISE	
  
•  NEUTRAL	
  SPINE	
  
•  INTERSEGMENTAL	
  STABILITY	
  REGIME	
  
•  GLOBAL	
  ABDO	
  WORK	
  
•  ADDRESS	
  SPECIFIC	
  WEAKNESS	
  
•  MOBLISE	
  DAY	
  0	
  OR	
  1	
  
•  FUNCTIONAL	
  ABDOMINAL	
  CONTROL,	
  GAIT	
  
•  AVOID	
  NEURAL	
  STRETCH	
  
POST-­‐OPERATIVE	
  DISCHARGE	
  
•  DISCECTOMY	
  :	
  DAY	
  0	
  
•  LAMINECTOMY	
  :	
  DAY	
  1/2	
  
•  FUSION	
  :	
  DAY	
  2/4	
  	
  
3	
  WEEK	
  POST-­‐OPERATIVE	
  REVIEW	
  
•  WOUND	
  REVIEW	
  
•  OSWESTRY	
  
•  PAIN	
  ISSUES	
  
•  ACTIVITY	
  LEVEL	
  
•  EXERCISE	
  UPGRADE	
  
•  STABILITY	
  	
  
•  GYM,	
  BALL,	
  POOL,	
  CARDIO	
  INCREASE	
  
6	
  WEEK	
  POST-­‐OPERATIVE	
  REVIEW	
  
•  WITH	
  SURGEON	
  
•  OSWESTRY	
  
•  PROGRESSIVE	
  BACK	
  CARE	
  
•  INVOLVE	
  EX.PHYSIOLOGIST	
  /	
  GYM	
  /	
  WORKPLACE	
  
•  SELF	
  MANAGED	
  PLAN	
  
MULTIMODAL	
  ROLE	
  
•  UNDERSTANDING	
  
•  RELATIONSHIP	
  
•  EARLY	
  ACTIVITY	
  
•  EARLY	
  EXERCISE	
  
•  EARLY	
  MOBILITY	
  
•  SHIFT	
  ONUS	
  OF	
  RESPONSIBILITY	
  
•  SELF	
  MANAGEMENT	
  
CONDITIONING	
  
•  GENERAL	
  AEROBIC	
  FITNESS	
  
•  POSTURAL	
  CORRECTION	
  
•  20-­‐30	
  MINUTE	
  PERIODS	
  
•  WEIGHT	
  LOSS	
  
•  POSITIVE	
  RATHER	
  THAN	
  PURELY	
  CLINICAL	
  SETTING	
  
NORMALISE	
  SETTING	
  :	
  TAI	
  CHI,	
  PILATES,	
  YOGA,	
  GYM	
  CLASSES,	
  SWIM	
  
	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  FOCUS	
  ON	
  SELF	
  MANAGEMENT	
  

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Back Rehabilitation

  • 1.   How  to  Manage     Non-­‐opera/ve  and  Opera/ve   BACK  REHABILITATION   Stephen  Boyd  -­‐  Physiotherapist  
  • 2. REHABILITATION  PRINCIPLE   •  Assess  any  Abnormality  and  treat  to  correct   the  Abnormality  
  • 3. SEVERE  LOW  BACK  PAIN   •  AIM  TO  REDUCE  PAIN  AND  INFLAMMATION   •  COMFORT  POSITONS  –  NEUTRAL  SPINE   •  ENCOURAGE  MOVEMENT  THAT  RELIEVES   •  BED  REST<48HRS   •  +/-­‐  TAPING   •  ANALGESIA  /NSAIDS   •  LOCAL  MODALITIES  FOR  PAIN/SPASM  (  HEAT,  ICE  ,  ELECTRO,  MANUAL   TH.)   •  EXERCISE  AWAY  FROM  AGGRAVATION   •  WATCH  FOR  NEURAL  SIGNS  
  • 4. SUB-­‐ACUTE  LOW  BACK  PAIN     OFTEN  WITH  ASSOC.  MUSCLE  SPASM  /  IRRITATION,  INCREASED  NEURAL   TENSION   HYPOMOBILE  SEGMENTS  –UTILISE  MANUAL  THERAPY       •  POOR  POSTURES,  BIOMECHANICS   •  REDUCE  PAIN  /  INFLAMMATION   •  RESTORE  ROM  (  MANUAL  THERAPY,  EXERCISE)   •  FLEXIBILITY  AND  STRENGTH   •  CARDIO  FITNESS   •  EDUCATION    
  • 5. REHABILITATION  AFTER  BACK   PAIN  EPISODE   •  MODIFY  ACTIVITIES   •  CORRECT  BIOMECHANICAL  ABNORMALITIES   •  POSTURAL  ASSESSMENT  OF  FUNCTIONAL  POSITIONS   •  LIFTING  MECHANICS   •  CORE  STABILITY  :  LOCAL  THEN  GLOBAL   •  ASSESS  /  STRETCH  TIGHTNESS   •  EDUCATION   •  HOME  EXERCISE  REGIME  
  • 6. ehR   REFERRAL    PRESCRIPTIONS   Acute  Back  Pain    Local  modali/es  for  pain/spasm    Encourage  non-­‐aggrava/ng  movement  and  exercise    Educate  /  encourage  neutral  spine    Manual  therapy  techniques    Home  exercise      Back  Care  advice      
  • 7. RehR   REFERRAL  PRESCRIPTIONS   SUB-­‐ACUTE  BACK  PAIN    Local  modali/es  for  pain/spasm/hypo  mobility    Restore  range  with  manual  therapy  and  exercise    Core  stability  regime  and  upgrade    Review  postures/biomechanics    Home  exercise  /  Cardio  fitness         CHRONIC  DISEASE  MANAGEMENT  PLAN  
  • 8. FUNCTIONAL  STABILITY         NEED  TO  UTILISE  BOTH  MUSCLE  FORCES  AND  PASSIVE  STRUCTURES  TO   DYNAMICALLY  STABILISE  THE  SPINE  FUNCTIONALLY     ANY  DEFICITS  ASSESSED  NEED  TO  BE  ADDRESSED  IN  A  REHAB.  PLAN  
  • 9. CORE  STABILITY     •  MUSCULAR  CONTROL  TO  MAINTAIN  FUNCTIONAL  STABILITY   •  MUSCULAR  CORSET   •  STABILITY  INVOLVES  PASSIVE  AND  ACTIVE  STIFFNESS   •  INSTABILITY  WHEN  EITHER  COMPONENT  DISTURBED  
  • 10. CORE  STABILITY   •  GLOBAL  :  DYNAMIC  /  PHASIC  MUSCLES  =  ACTIVE  TRUNK  MOVEMENT   •  RECTUS  ABDOMINIS   •  EXTERNAL  OBLIQUES   •  ILIOCOSTALIS  (THORACIC  PART)   •  LATISSIMUS  DORSI   •  LINK  PELVIS  TO  THORACIC  CAGE  
  • 11. CORE  STABILITY   •  LOCAL  :  POSTURAL  /  TONIC  =  INTERSEGMENTAL  STABILITY   •  TRANSVERSUS  ABDOMINIS   •  MULTIFIDIS   •  PSOAS  MAJOR   •  QUADRATUS  LUMBORUM   •  DIAPHRAGM   •  ILIOCOSTALIS  (  LUMBAR  SEGMENT)   •  INTERNAL  OBLIQUE  
  • 12. STABILITY  TEACHING/ RETRAINING   •  EDUCATION  :  ANATOMY  AND  FUNCTION   •  ISOLATE  DEEP  LAYER  T.A   •  MOTOR  RELEARNING   •  TRAIN  STABILISERS  IN  ISOLATION   •  ADD  FUNCTIONAL  MOVEMENTS  WITH  STABILITY   •  PAINFREE     •  NEUTRAL  SPINE  INITIALLY   •  FEEDBACK  :  TACTILE  ,  PBU,  ULTRASOUND  
  • 13. STABILISATION  EXERCISES   •  INITIATE  PELVIC  FLOOR    HELPS  ISOLATE  T.A.   •  PALPATE  1CM  IN  1CM  DOWN  A.S.I.S.   •  FEEL  TENSION,  NOT  BULGE   •  CONTROLLED  BREATHING   •  SUPINE  /  4  POINT  KNEEL  /  STANDING  /  SITTING  
  • 14. STABILISATION  EXERCISES   •  ISOMETRIC  ABDOMINALS  IN   SUPINE   •  SIDE  LYING  +  GLUTEUS   MEDIUS   •  SUPINE  BRIDGE   •  ABDOMINAL  CURL   •  4  PT  KNEEL   •  PRONE  PLANK   •  SIDE  PLANK   •  STANDING  LUNGES   •  STEP  UPS   •  GYM  BALL  SEATED     •  GYM  BALL  LIFTING   •  BALANCE  DISC    
  • 15.
  • 16.
  • 17.
  • 18.
  • 19.
  • 20. STRETCHING   •  LUMBAR  ROTATION   •  LUMBAR  FLEXION   •  HIP  FLEXION   •  HIP  EXTENSION   •  HIP  ADDUCTION   •  STRAIGHT  LEG  RAISE   •  DEEP  HIP  ROTATORS   •  THORACO-­‐LUMBAR  ROTATION   •  LUMBAR  EXTENSION  
  • 21. POST-­‐OPERATIVE   REHABILITATION   •  UNDERSTANDING  THE  SURGERY   •  REALISTIC  GOALS  /  TIMELINES   •  PAIN  CONTROL   •  EARLY  EXERCISE   •  EARLY  MOBILITY   •  DISCHARGE  WITH  REHABILITATION  PACKAGE  
  • 22. POST-­‐OPERATIVE  EXERCISE   •  NEUTRAL  SPINE   •  INTERSEGMENTAL  STABILITY  REGIME   •  GLOBAL  ABDO  WORK   •  ADDRESS  SPECIFIC  WEAKNESS   •  MOBLISE  DAY  0  OR  1   •  FUNCTIONAL  ABDOMINAL  CONTROL,  GAIT   •  AVOID  NEURAL  STRETCH  
  • 23. POST-­‐OPERATIVE  DISCHARGE   •  DISCECTOMY  :  DAY  0   •  LAMINECTOMY  :  DAY  1/2   •  FUSION  :  DAY  2/4    
  • 24. 3  WEEK  POST-­‐OPERATIVE  REVIEW   •  WOUND  REVIEW   •  OSWESTRY   •  PAIN  ISSUES   •  ACTIVITY  LEVEL   •  EXERCISE  UPGRADE   •  STABILITY     •  GYM,  BALL,  POOL,  CARDIO  INCREASE  
  • 25. 6  WEEK  POST-­‐OPERATIVE  REVIEW   •  WITH  SURGEON   •  OSWESTRY   •  PROGRESSIVE  BACK  CARE   •  INVOLVE  EX.PHYSIOLOGIST  /  GYM  /  WORKPLACE   •  SELF  MANAGED  PLAN  
  • 26. MULTIMODAL  ROLE   •  UNDERSTANDING   •  RELATIONSHIP   •  EARLY  ACTIVITY   •  EARLY  EXERCISE   •  EARLY  MOBILITY   •  SHIFT  ONUS  OF  RESPONSIBILITY   •  SELF  MANAGEMENT  
  • 27. CONDITIONING   •  GENERAL  AEROBIC  FITNESS   •  POSTURAL  CORRECTION   •  20-­‐30  MINUTE  PERIODS   •  WEIGHT  LOSS   •  POSITIVE  RATHER  THAN  PURELY  CLINICAL  SETTING   NORMALISE  SETTING  :  TAI  CHI,  PILATES,  YOGA,  GYM  CLASSES,  SWIM                                                                    FOCUS  ON  SELF  MANAGEMENT