Presented by: Stephen Boyd — Physiotherapist Event: GP Education Day - 2013

1. How to Manage
Non-operative and Operative
BACK REHABILITATION

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. 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

7. CORE STABILITY
• MUSCULAR CONTROL TO MAINTAIN FUNCTIONAL STABILITY
• MUSCULAR CORSET
• STABILITY INVOLVES PASSIVE AND ACTIVE STIFFNESS
• INSTABILITY WHEN EITHER COMPONENT DISTURBED

8. CORE STABILITY
• GLOBAL : DYNAMIC / PHASIC MUSCLES = ACTIVE TRUNK MOVEMENT
• RECTUS ABDOMINIS
• EXTERNAL OBLIQUES
• ILIOCOSTALIS (THORACIC PART)
• LATISSIMUS DORSI
• LINK PELVIS TO THORACIC CAGE

9. CORE STABILITY
• LOCAL : POSTURAL / TONIC = INTERSEGMENTAL STABILITY
• TRANSVERSUS ABDOMINIS
• MULTIFIDIS
• PSOAS MAJOR
• QUADRATUS LUMBORUM
• DIAPHRAGM
• ILIOCOSTALIS ( LUMBAR SEGMENT)
• INTERNAL OBLIQUE

10. 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

11. 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

12. 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

13. POST-OPERATIVE REHABILITATION
• UNDERSTANDING THE SURGERY
• REALISTIC GOALS / TIMELINES
• PAIN CONTROL
• EARLY EXERCISE
• EARLY MOBILITY
• DISCHARGE WITH REHABILITATION PACKAGE

14. 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

15. POST-OPERATIVE DISCHARGE
• DISCECTOMY : DAY 0
• LAMINECTOMY : DAY 1/2
• FUSION : DAY 2/4

16. 3 WEEK POST-OPERATIVE REVIEW
• WOUND REVIEW
• OSWESTRY
• PAIN ISSUES
• ACTIVITY LEVEL
• EXERCISE UPGRADE
• STABILITY
• GYM, BALL, POOL, CARDIO INCREASE

17. 6 WEEK POST-OPERATIVE REVIEW
• WITH SURGEON
• OSWESTRY
• PROGRESSIVE BACK CARE
• INVOLVE EX.PHYSIOLOGIST / GYM / WORKPLACE
• SELF MANAGED PLAN

18. MULTIMODAL ROLE
• UNDERSTANDING
• RELATIONSHIP
• EARLY ACTIVITY
• EARLY EXERCISE
• EARLY MOBILITY
• SHIFT ONUS OF RESPONSIBILITY
• SELF MANAGEMENT

19. STRETCHING
• LUMBAR ROTATION
• LUMBAR FLEXION
• HIP FLEXION
• HIP EXTENSION
• HIP ADDUCTION
• STRAIGHT LEG RAISE
• DEEP HIP ROTATORS
• THORACO-LUMBAR ROTATION
• LUMBAR EXTENSION

20. ASSESSING FUNCTIONAL CORE
STABILITY
• MANUAL SHEAR TEST
• LUMBAR TORSION TEST
• PRONE BRIDGE
• LATERAL BRIDGE
• SEATED TORSO FLEXION
• PRONE EXTENSOR ENDURANCE TEST
• SINGLE LEG SQUAT

21. 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