Breakout session with Dr Angus Forbes and Stephen Boyd

1. Lumbar disc herniation

2. Natural history
• Degeneration
• Up to 90% improve without surgery
• Discectomy gives excellent results in 80-90%
• Great for leg pain
• Success = decreased pain and ability to return to work,
daily activities (not pain free)
• Worse outcomes in work related/legal cases

3. Role of Passive Therapy Pre op
• Massage for spasm/tightness
• Stretches for adjacent joints
• Ice/Heat
• Positions of comfort/relief
• Painfree exercise, activity (cardio, normalise activity)
• Often “over therapied”
• Often differing advice from many sources : try offer
appropriate advice
• Avoid neural stretches!!

4. Post Discectomy Rehab
Cochrane review
• Neural mobilisation not effective for pain/functional
disability
• Post op rehab exercise program reduces pain v’s no
rehab
• High intensity rehab better results than low intensity
• No studies show early activity leads to re-operation
• Not harmful to return to activity post op
• Not necessary to stay passive

5. Post Discectomy Rehab
• Day Surgery:
• Education/exercise program (self managed with
upgrade)
• Activity guidelines (self managed)
• 2-3 weeks:
• Clinic vs phone
• Education: exercise/activity upgrade
• Work status
• 6 weeks:
• Exercise/activity/work review
• Exercise Physiologist review

6. Post discectomy exercise
• Hip/knee flexion

7. Post discectomy exercise
• Single leg supine bridge

8. Post discectomy exercise
• Modified Side Bridge

9. Post discectomy exercise
• Swissball Abdominal Brace

10. Activity Guide

11. Activity Guide

12. Activity Guide

13. Return to work guidelines
• Good work is good for you
• Recurrence
• Capacity and tolerance
• Medication side effects

14. Return to work guidelines
• Restricted/alternate duties
• Overhead, bending, carrying, lifting & prolonged
sitting
• Position descriptions
• Biopsychosocial

15. Discogenic back pain /
degenerative

16. Natural history of LBP
• Lifetime incidence up to 90%
• 8% of all Workcover QLD lodgments in 2014-15.
(Most common cause for common law claim)
• Statutory claim payments $75million
• Cause
• 30% of population without back pain have disc
degeneration

17. Natural history of LBP
• Treatment
• Conservative
• 50% improved within 1 week
• 90% in 12 weeks
• Steroid
• Surgery
• Recurrence
• Up to 80% in 2 years

18. Work as a cause of nonspecific back
pain and WorkCover certification
Work relevant or work related?

19. Discogenic back pain
• Most settle in 4 weeks
• 90% settle in 3 months
• 5% develop low back pain, chronic
• Multidiscipline approach is important
• Remain active
• Educate: shows improved outcomes; positions of ease,
posture, exercise, lifting and activity techniques

20. Therapy Role
• Education: consistent
• Exercise
• Postural correction
• Manual therapy

21. Exercise for Discogenic LBP
• Avoid forward slouch
• Exercise in comfortable range

22. Exercise for Discogenic LBP
• Prone on elbows

23. Exercise for Discogenic LBP
• Lumbar-hip Mobility

24. Exercise for Discogenic LBP
• 4 point kneel with arm raises

25. Exercise for Discogenic LBP
• Supine Swissball Hold with arms

26. Exercise for Discogenic LBP
• Hydrotherapy

27. Exercise for Discogenic LBP
• POOR Exercise Prescription

28. Lumbar stenosis

29. Background
• Incidence / prevalence >50yrs
• 5:1000
• Cause
• Primary
• Secondary
• Symptoms
• Fatigue caused by walking relieved by rest

30. Background
• Tests
• MRI
• Treatment
• Medication
• Steroid
• Surgery

31. Stenosis
• Extension-related pain
• Exercise in neutral spine and in flexion

32. Exercise for stenosis
• Supine crook lying rotation

33. Exercise for stenosis
• Supine Knee Tuck

34. Exercise for stenosis
• Supine Pelvic tilt

35. Exercise for stenosis
• Supine Pelvic tilt on Roller – variations

36. Exercise for Stenosis
• POOR exercise prescription

37. Rehab: elderly patient post Fusion
• 3-4 nights inpatient
• Mobilise day 0
• Consider co-morbidities (cardio, THR, TKR, OA)
• Education, simple exercises
• No Corset/Brace
• Review 3 weeks ( clinic / phone)
• Review 6 weeks + xray + Exercise Physiologist as
appropriate