RNOH Physiotherapy Department ( ) Rehabilitation guidelines for patients undergoing spinal surgery

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1 RNOH Physiotherapy Department ( ) Rehabilitation guidelines for patients undergoing spinal surgery As a specialist orthopaedic hospital we recognise that our broad and often complex patient group needs an individualised rehabilitation approach. This takes into consideration the multi factorial components contributing to back pain. Milestone driven These are milestone driven guidelines designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the outpatient clinic at the RNOH by helping the patient and therapist to identify when specialist review is required. Rehabilitation guidelines for patients undergoing lumbar discectomy Indications: Leg pain secondary to nerve root compression (radiculopathy), often with lower back pain Possible complications of surgery: Infection [<1%] Nerve damage [less than 1%] Ongoing back/leg pain [5-10% long term] Dural tear [<5%, higher if prior surgery] Recurrence [<10% at up to 10 years] Expected outcome: Patient reports good relief of leg pain and a significant decrease in back pain. Back pain can persist and sitting tolerance can be decreased. Improvements can continue for up to 18 months post operatively Pre-operatively When practical the patient will be seen pre-operatively and with consent, the following assessed as indicated: Current functional levels General health Social/work/hobbies Posture Functional R.O.M., e.g. dressing/bending, sitting, sit stand and stairs if appropriate

2 Gait/Mobility including any walking aids, corsets etc Neurological function and pathodynamics Post-op expectations, especially long-term self-management and precautions Patient information leaflet issued to the patient and exercises taught with warnings Post-operative management explained and log-rolling practised Post-operatively Always check operation notes and post-op instructions. Discuss any deviation from routine guidelines with team concerned. NB: If dural tear intra-operatively, patient may complain of intense, severe low pressure headache (i.e. worse on sitting up). In this instance, mobilise as comfort allows, only after period of flat bed rest prescribed by surgeon (usually between 48 hours and 5 days). Initial rehabilitation phase: 0 4 weeks Goals: 1. Mobilise independently and safely 2. Understand good posture and spinal mechanics 3. Independent in home exercise programme (HEP) 4. Understand self-management and pacing concept particularly with ADL and PDL 5. Return to driving at 4-6 weeks Precautions For the first 4 weeks, whilst the initial post operative pain settles and the disc begins to heal, it is advised to be careful with some activities. A sensible approach is advised and a gradual increase in activities recommended.current evidence supports a steady paced up increase in activity whilst respecting post operative soreness, disc healing times, neural sensitivity and patient s previous level of fitness. 1. Sitting should be gradually built up during activities such as eating or relaxing and should be guided by the development of symptoms. A limit of mins is sensible for the first few days, and once this is comfortable it can be increased gradually. If a long journey is unavoidable e.g. to get home from hospital, the patient can recline as a passenger and ensure breaks every minutes to mobilise. 2. Avoid prolonged-sitting [>1 hour] for about 4 weeks until neural sensitivity has settled and strength improved and can then try with care, e.g. in the bath. 3. Walking is unrestricted, and should be increased day by day as comfort allows. 4. Caution with flexion in sitting and standing for the first 4 weeks. 5. Avoid driving until about 3-4 weeks post-operation, or longer if there is a significant loss of function or sensation in one or both legs/feet. The patient should be able to sit

3 comfortably in the driving position,drive safely,turn to look in the mirror and have 100 % reaction times for an emergency stop. 6. For the 1 st few days only lift about 1kg (a ½ full kettle ) and then slowly increase. 7. Continue to log-roll until neural sensitivity has settled and strength improved which takes about 2-4 weeks. Treatment Pain relief: Ensure adequate analgesia; suitable positioning. Patient education: Advice given on sitting relating to patient s function. Reinforce self-management and building up of activities appropriately. Precautions as above Postural awareness: Advice given on the importance of good posture especially in sitting. Exercises: Teach core stability exercises in lying and in functional positions. Teach lying to standing through side-lying. Teach exercises from patient information leaflet. Mobility: Ensure patient is independent with transfers and mobility, including stairs if appropriate. Pre- operative status will affect outcome. If a walking aid is given and was not used pre-operation, the surgical team will be informed. On discharge home from hospital Ensure all patients have outpatient physiotherapy arranged. The patient should aim to achieve: 1. Independent and safe mobility, including stairs if appropriate 2. Independent and safe in home exercise programme 3. Independent in transfers Milestones to progress to next rehab phase: 1. Adequate pain relief 2. Basic core stability 3. Starting to build-up normal activities 4. Normal gait pattern 5. Increasing sitting tolerance Recovery/rehabilitation phase: 4 20 weeks Goals:

4 1. Increase normal activity and function 2. Return to work at 4 weeks (see restrictions below) 3. Return to sport/gym at 4 weeks (see restrictions below) 4. Optimise normal movement 5. Increase lifting Restrictions These are designed to allow the disc to continue to heal and the neural sensitivity to settle. It is balanced against the evidence supporting the return to early function and activity which decreases the risk of a poor outcome. 1. An appropriate return to work should be planned for about 4 weeks and it should be phased /part time if appropriate especially if there is a lot of travelling/sitting. If the job involves heavy manual work the aim would be to return by 3 months with a planned phased return if appropriate 2. Avoid heavy lifting [>10 kg] until 12 weeks post-operation or until the surgeon advises. 3. Contact sports should be avoided until about 3-4 months or at the surgical team s discretion Treatment Pain relief: Ensure appropriate amount of exercise and activity with appropriate analgesia. Patient education: Pacing activities within appropriate restrictions. Ensure patient not over or under exercising. Exercise cautiously particularly with previously aggravating activities. Postural awareness and encourage normal movement patterns. Advice on healing times of disc; not smoking and body weight control. Postural awareness: Reinforce importance of good posture especially when sitting, e.g. at work, driving and in the bath. Advise on good practice of changing posture regularly. Exercise: Progress core stability to include leg slides, gym ball, balance work and proprioceptive training. Progress functional range of movement, avoiding sustained flexion and extension. General fitness advice, e.g. swimming-start initially with backstroke and addin other strokes as long as comfortable. Can attend gym and return to sport (see restrictions). Trunk, upper and lower limb conditioning as relevant to patient s goals. Manual therapy: Soft tissue/joint mobilisations/neuropathodynamics treatment as appropriate. Milestones to achieve by 20 weeks

5 Recovery can continue up until 18 months so expectations must be individual and realistic: 1. Achieve realistic goals set by patient 2. Return to normal activities 3. Minimal leg pain 4. Continuing with paced exercise programme and good posture Failure to meet milestones: Refer back to surgical team Continue with outpatient Physio whilst still making progress Consider Referral for rehab/active back programme Failure to progress If a patient is failing to progress, then consider the following: Possible problem Causes Action Leg pain Neural sensitivity Can take up to 4 weeks to decrease Ensure adequate analgesia Keep exercises pain-free Decrease sitting times slightly Progressing activities too quickly or too slowly If persists, refer back to surgical team Neurological Further disc Review pre-operative neuro status deterioration complications Closely monitor and inform surgical team Inflamed wound Possible infection Refer to surgical team or GP Exercises painful Patient not exercising regularly enough or following restrictions Altered neuropathodynamics Back pain Poor technique Irritable back still Poor compliance patient Common. Spinal motion segment changes. Check not returning to activities too quickly Check technique Alter exercise programme and correct technique Ensure exercises are focussed and relate to function Explain importance of good muscle function and posture to avoid flare-ups Assess and treat accordingly Ensure adequate analgesia Ensure exercises are appropriate and not increasing too quickly or too slowly Not sitting or walking too much Reassure it can be common

6 Headaches Dural tear (1 st 4 weeks ) Postural or Altered neuropathodynamics other pathology If has dural tear during surgery, this can take up to 2 weeks to settle If onset is after 4 weeks post-op, assess and treat if appropriate and liaise with referrer Summary of evidence for physiotherapy guidelines A comprehensive literature search was carried out to identify research relating to rehabilitation following lumbar discectomy surgery. After reviewing the articles and information found including discussion with other physiotherapists on the interactive CSP website,the physiotherapy guidelines were produced on the best evidence available. 1.Danielsen,JM et al. Early aggressive exercise for post operative rehabilitation after discectomy. Spine Vol 25(8) p Scrimshaw S,Maher C Randomised Controlled Trial of Neural Mobilisation after Spinal Surgery.Spine 2001,vol26 (24) p Kjelby-Wendt G,Styf J, Early Active Training after lumbar discectomy :A Prospective,Randomised and controlled study Spine 1998 vol 23 (21) pp Carragee E,Helms E, O Sullivan G Are postoperative Activity restrictions necessary after posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases. Spine 1996 vol 21 (16) p Bradley A,Lui W, Herkowitz H,Panjabi M,Tech,Guiboux J Effect of anular repair on the healing strength of the intervertebral disc; a sheep model Spine 2000,vol 25 (17) p Ostelo-RWJ,de Vet HCW,Waddell-G,Kerckhoffs,Leffers-P,Van-Tulder-MW Rehabilitation after lumbar disc surgery The Cochrane Library,2006 no1 (CD003007) 7.Sparkes V., Laing.J.C., Prevost,A.T., Bradley M. The effect of a muscle stabilisation programme on function and the cross-sectional area of the lumbar multifidus after surgery for prolapsed intervertebral disc Physiotherapy 2004 vol 2004 p167