Rehabilitation following lumbar fusion

Staying active speeds recovery from fusion

Patients who have had or are contemplating lumbar fusion surgery are understandably concerned about making sure the fusion heals as intended. For this reason, many patients are afraid to be active and some do not want to move at all, fearing that they will risk having the fusion not set up properly. In actuality, and contrary to this fear, movement is very important to foster healing. There are precautions to keep in mind – most patients avoid bending, lifting, and twisting – but staying active with short, frequent, gentle exercise is strongly recommended and delivers many benefits.

1. Movement activates supporting muscles. Following surgery or an episode of injury, smaller muscles in the area may become inhibited (turned off). These muscles have a great responsibility in maintaining stability of the spine. Encouraging the muscles to function properly will also reduce stress through the surgical site by active stabilization.

2. Gentle stretching promotes flexibility. During periods of inactivity, range of motion can be lost, and stiffness soon settles in. Very gentle stretching of the core back and abdominal muscles, as well as the hip muscles attached to the spine and pelvis, will make all movement easier, even just getting out of a chair. Care must be taken to not be too aggressive too early, or a set back could undercut the benefit intended.

3. Activity encourages healing blood flow. Blood brings the oxygen required to the healing site. Lack of oxygen will delay or sometimes prevent healing of tissues and healthy bone growth, which are critical to a successful fusion outcome.

Illustrative post-fusion near-term rehabilitation program

Meeting with a physical therapist before or within days after surgery is beneficial so specific direction can be given on when to begin various types of exercise. Because surgeons use different techniques and approaches during fusion (for example, access to the spine can be achieved through incisions in the front, the back or both), some exercises may not be appropriate for all patients. The technique used will influence what rehabilitation should be done. What follows is a general guideline for post-operative rehabilitation that can be customized for each patient.

Day 1/Week 1 – Limit exercise to short walks

The patient must move frequently beginning the first day after surgery. The patient should walk as often as the surgeon allows, to the point of minor aching, but stop if there is any sharp pain.

Most surgeons will encourage patients to get out of bed and walk the first day after surgery, and recommend walking frequently throughout the initial recovery period, increasing the amount and length of the walks as tolerated.

Days 1-7/Week 1 – Start stretching

Stretching the hamstrings and quadriceps is particularly important, as well as the middle back where the nerve root is located to prevent formation of adhesions or scarring of the nerve. Stretching of muscles should be done slowly with 30 second holds, three repetitions, two sets per day. Nerve stretches (mobilization) should be done in a “pumping” fashion without long hold times, and can be done every two hours. Pain should be avoided.

Illustrative stretching movements

1. A nerve stretch is achieved by lying on the back with legs on the ground, and slowly lifting one leg until a stretch is felt in the back of the thigh and through the hip. While supporting the raised leg with hands behind the knee, pump the ankle while holding the knee still. See Figure 1.

• Variation: An active hamstring stretch can be done from the same position. While lying on back, bend both knees. Slowly straighten one leg and pushing the heel toward the ceiling until a stretch is felt. Alternate stretching each leg. See Figure 1.
  
  

2. A seated hamstring stretch can be performed while sitting on the edge of chair. Straighten one leg in front with toes pointed up and knee straight. Push belly forward to move into stretch while keeping chest high. See Figure 2.

3. The quadriceps flexion stretch is done while lying on the stomach, and bringing heel toward buttocks as far as possible. See Figure 3.

Weeks 1-9 – Include static stabilization exercises

These movements are described as “static” because they are done without moving the trunk. They should be completed by moving arms and legs while avoiding any rocking or arching of the lower trunk.

Illustrative stabilization exercise movements

4. A pelvic tilt involves lying on your back on the floor with knees bent and pulling the belly in towards the spine. This position is the basis for keeping the lumbar spine stable. See Figure 4.

5. March in place by lifting alternating legs 3-4 inches above the floor without letting the pelvis rock side to side. See Figure 5.

6. Form a bridge with trunk raised by raising hips from floor and keeping a straight line from shoulders to hips. See Figure 6.

7. Extend the upper body by lying on the stomach and squeezing shoulder blades together while slowly raising head and shoulders only one inch off floor. Keep looking down at the floor throughout the exercise. See Figure 7.

8. Also while lying on the stomach, extend hip muscles by raising one leg at a time holding the knee straight. Avoid any rocking of the pelvis. See Figure 8.

9. Exercise the upper back muscles by using an elastic band positioned around a stable object and performing a “rowing” motion with arms pulled back and shoulder blades together with the chest supported. See Figure 9.

By: Ron Miller, PT
November 30, 2006