Artificial Disc

Advanced Orthopedics and Sports Medicine

Post Operative Spine RehabArtificial Disc Protocol Treatment Guideline

Precautions

• Avoid Extension for 6 weeks (treat like Spondylolisthesis with flexion bias)
• Avoid Rotation for 6 weeks postop
• Avoid active sports for 3 months post op (No contact sports)
• Avoid exercise that increases Sciatic type pain

Phase I: Immediate post Surgical Phase (IPSP) 06 weeks

Goals:

• Decrease pain and inflammation.
• Increase activity tolerance.
• Encourage wound healing.
• Increase aerobic tolerance (independent with home program 20 min tolerance to exercise).
• Monitor for signs of possible infection.
• Educate on body mechanics and posture for bed mobility

Precautions:

• Prevent excessive initial mobility or stress on tissues
• Avoid lifting, twisting of the lumbar spine for 6 weeks
• Avoid rotation and extension for 6 weeks

Treatment Summary:

• Education on bed mobility and transfers with proper spine positioning.
• Reinforce basic postop home exercise program including
  • Ankle pumps
  • Long arc and short arc quadriceps
  • Diaphragmatic breathing
  • Relaxation exercises
  • Abdominal isometric exercises
• Increase tolerance to walking to ½ mile daily (1530 min cardiovascular activity)
• Reinforce sitting, standing and ADL modifications with neutral spine and proper body mechanics.

Criteria for progression:

• Pain and swelling within tolerance.
• Independent HEP
• Tolerance of 15 min of exercise and 1530 min of cardiovascular exercise.
• Functional ADL for self care/hygiene
• Symptoms decrease by 50%.

Phase II: Initiation of OPPT 69 weeks/23 times per week

Goals:

1. Patient education/Back school
2. Reestablish neuromuscular recruitment of the multifidus (Functional dynamic lumbar stability)
3. Normalization of flexibility deficits in extremities
4. Normalization of any gait deviations
5. Return to activities of daily living
6. Improve positional tolerances for return to work

Precautions:

1. Avoid lumbar loading
2. Avoid twisting and bending of the lumbar spine.
3. Limit lumbar extension

Treatment Summary:

• Back Education Program
  • Anatomy, Pathology, & Biomechanics
  • Reinforce neutral spine positioning
  • Body mechanics and training: Performance of functional activities with neutral spine and
    protective positions
• Manual Therapy:
  • Grade 1 or grade 2 joint mobs for neuromodulation of pain
  • Scar tissue mobilization. Educate patient on self mobilization of scar.
  • Soft tissue mobilization of soft tissue restrictions.
• Exercises:
  • Train Neutral lumbar position: Create independent movement of the pelvis and then find and
    maintain a neutral position of the lumbar spine.
  • Diaphragmatic breathing: Proper breathing technique without the use of accessory respiratory
    muscles
  • Neural mobilization exercises. Do not reproduce symptoms
  • Pelvic stabilization exercises with emphasis on transverse abdominals and multifidus
  • Unloaded Pelvic and Lumbar ROM (supported): Pelvic rocks, Wig wags, Pelvic clocks. All
    performed in neutral and protective positions. Flexion based program including single and
    double knee to chest, seated or standing marches.
  • Hip and knee flexibility exercises: Decreases stress on lumbar spine and makes it easier to
    maintain neutral spine. (hamstrings, piriformis, gluteal, quads, hip flexors, gastroc, soleus etc)
  • Closed Chain exercises including wall slides, wall press (supine), squat machine
  • Initiate acquatics (if available and indicated)
    Cardiovascular training, treadmill, UBE, stationary bike (patient must have good pelvic
    control)
    Initiate balance exercises (week 1012)
  • Address other mechanical restrictions as needed
    Modalities for symptom modulation if needed

Criteria for progression:

1. Patient has working knowledge of body and lifting mechanics.
2. Able to hold cocontraction of multifidus/transverse abdominals for 60 sec
3. Cardiovascular tolerance to 30 min/day
4. Dynamic sitting and standing tolerance of 1560 min

Phase III: Advanced PT 912 weeks/23 times per week.

Goals:

• Progress with strengthening and flexibility exercises.
• Initiate lifting and posture training
• Progress stabilization and trunk control
• Progress to premorbid activity

Treatment Summary:

• Manual Therapy:
  • Joint mobilization of adjacent restrictions of thoracic spine, hip/pelvis.
  • Soft tissue mobilization of soft tissue restrictions.
• Exercises:
  • Continue with ROM exercises for lumbar spine including cat/camel, seated and standing
    active rotation.
  • Advanced balance exercises
  • Neural mobilization exercises.
• Advanced stabilization and proprioceptive training, Multiplane stabilization/mobility
• Advanced Hip/Core strengthening exercises: Functional exercises like chops/diagonal lifts,
  squatting, lunging
• Lifting training with proper posture. (floor to waist and waist to shoulder level)
• Body mechanics drills
• FCE if appropriate

Criteria for discharge:

1. Manual muscle testing is within functional limits
2. Independent with gym program
3. Trunk ROM within functional limits
4. Symptoms decrease by 75%.
5. Postural tolerance to 60 min

Pearls of rehab:

• Focus on local muscle systems (tonic/postural/stabilizing) lumbar multifidus, internal oblique,
  transverse abdominals, psoas major, quadratus lumborum, lumbar portion of lumbar iliocostalis
  lumborum before global (phasic/primary movers) such as rectus abdominals, external oblique,
  and portion of iliocostalis lumborum. Local muscles are shorter in length and closer to axis or
  rotation while the global muscles have no direct attachment on the spine.
• Avoid preloading the spine in posterior pelvic tilt.
• Avoid prone upper body extensions, or prone leg extensions to avoid high compressive load of
  the already weakened spine)
• Nopain no gain axiom usually does not apply to the spine
• Because of diurnal variations in fluid level of the intervertebral disks (more hydrated early
  morning) it would be unwise to perform full range spinal motions (bending) shortly after rising
  from the bed
• Focus on low load high repetitions to improve endurance rather than high load low repetition for
  strength.
• There is some evidence that low back exercises are most beneficial when performed daily.
• Focus on pain relief with Oswestry scores of 4060, with scores of 2040 focus on decreasing
  pain, muscle reeducation, gradual strengthening, flexibility and improve cardiovascular
  endurance, with scores less than 20 focus on work simulation and progressive strengthening