Kyphoplasty

Advanced Orthopedics and Sports Medicine

Post Operative Spine Rehab-Kyphoplasty/Vertebroplasty – Treatment Guideline

Phase I: Immediate post Surgical Phase (IPSP) 0-2 weeks

Goals:

1. Decrease pain and inflammation.
2. Increase activity tolerance.
3. Encourage wound healing.
4. Increase aerobic tolerance (independent with home program 20 min tolerance to exercise).
5. Educate on body mechanics and posture for bed mobility

Precautions:

1. Prevent excessive initial mobility or stress on tissues.
2. Avoid lifting, twisting and bending of the spine.

Treatment Summary:

1. Education on bed mobility and transfers with proper spine positioning.
2. Reinforce basic post-op home exercise program including
1. Ankle pumps
2. Long arc and short arc quadriceps
3. Diaphragmatic breathing
4. Relaxation exercises
5. Abdominal isometric exercises
3. Increase tolerance to walking (½ mile daily) or bike (15-30 min cardiovascular activity)
4. Reinforce sitting, standing and ADL modifications with neutral spine and proper body mechanics.

Criteria for progression:

1. Pain and swelling within tolerance.
2. Independent HEP
3. Tolerance of 15 min of exercise and 1530 min of cardiovascular exercise.
4. Functional ADL for self care/hygiene

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

Goals:

1. Patient education/BackNeck school
2. Reestablish neuromuscular recruitment of the longus colli (Functional dynamic 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 excessive cervical loading
2. Avoid twisting and bending of the lumbar spine.

Treatment Summary:

• Back Mechanics 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 mobilization. Educate patient in scar mobilization.
• Exercises:
  • Train Neutral lumbar position/cervical posture: Create independent movement of the pelvis
    and then find and maintain a neutral position of the lumbar spine. Maintain god neck posture
  • Diaphragmatic breathing: Proper breathing technique without the use of accessory respiratory
    muscles
  • Pelvic stabilization exercises with emphasis on transverse abdominals and multifidus
  • Knee strengthening exercises.
  • Unloaded trunk ROM exercises: Lumbar spine flexion and extension in quadruped (cat
    camel) Pelvic rocks, Wig wags, Pelvic clocks.
  • 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)
  • Initiate acquatics (if available and indicated)
  • Cardiovascular training, treadmill, UBE, stationary bike (patient must have good pelvic
    control)
  • Initiate balance exercises sitting and standing. Progress double leg firm surface to foam
    surface, eyes open/closed, single leg balance, reaching outside BOS
  • Gait training with or without assistive device as needed.
  • 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. Cardiovascular tolerance to 30 min/day
3. Dynamic sitting and standing tolerance of 15-30 min

Phase III: Advanced PT 4-8 weeks/2-3 times per week.

Goals:

1. Progress with strengthening and flexibility exercises.
2. Advanced lifting and posture training
3. Address return to work/recreational activity concerns
4. Advanced stabilization and trunk control

Treatment Summary:

• Activity specific training
• Exercises (Advanced strengthening); (based on degree of bone loss, age and functional status
  of the individual)
  • Increasing complexity and load of exercises maintaining lumbar spine stability:
    supine SLR all directions, single leg bridging, bridging on unsteady surfaces, alternate arm an leg extensions in quadruped, prone on ball leg and arm extensions (quadruped), functional co-contractions during walking increasing speed and other activities (kneeling, squatting, stairs etc)
• Advanced Hip/Core strengthening exercises: Functional exercises like chops/diagonal lifts,
  squatting, lunging.
• Advanced cardiovascular training
• 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 home program
3. Cervical ROM within functional limits

Pearls of rehab:

• Exercises to avoid with Osteoporosis:
  • Dynamic abdominal exercises (eg sit ups)
  • Twisting movements (eg golf swing)
  • Trunk flexion
  • Abrupt or explosive loading
  • High impact loading.
• 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)
• No-pain 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 40-60, with scores of 20-40 focus on decreasing
  pain, muscle re-education, gradual strengthening, flexibility and improve cardiovascular
  endurance, with scores less than 20 focus on work simulation and progressive strengthening.