The abundance of cases that involve low back pain reminds one of a plague spread throughout the world. The lumbar spine is considered the most supportive part of the spine with weight bearing features; however, neglecting the initial symptoms of low back pain can lead to irreversible changes and further serious damage to the spine structures and peripheral nervous system. Low back problems are “the most common cause of job related disability” since “about 80 percent of adults experience low back pain at some point in their lifetimes” (NINDS facts sheet).
Chronic low back pain may require surgical intervention ith the goal to alleviating pain and decompressing the nerve structures. The following case describes the particular patient’s diagnosis and related issues during the rehabilitation process on practice and demonstrates the specific theory suggestions on rehabilitation after spinal surgery. Patient S. , forty year old male of Middle Eastern descent, was admitted to the hospital for the treatment of a protruding L4-L5 spinal segment disc with symptoms of an impinged nerve that resulted in right leg weakness and complete foot drop.
The diagnosis of a L4-L5 intervertebral disk protrusion required a discectomy and aminectomy of this particular segment with following L4-L5 vertebrae arthrodesis (fusion). Spinal fusion surgery is indicated for stabilization of particular spinal segments. This instability was caused by the discectomy, the procedure that was required to minimize the pressure on the nerves adjacent to disc protrusion site (NIAMS). The patient began the physical therapy rehabilitation status post two days from posterolateral lumbar fusion.
The patient’s past medical history revealed that the onset of the persistent lumbar radiculopathy symptoms occurred almost a year prior to the operation. During that eriod of time he continued to experience a radiating pain down the right posterior thigh culminating in right foot drop and numbness in his leg. Though the patient’s weight, which is very often the cause of low back pain, was in a normal range, his sedentary lifestyle and office job contributed to the incorrect postural alignment and weak core musculature that was probably the main contributing pathological factor.
The clinical presentation at the first therapy session included the weakness in the right leg with Anterior Tibialis paresis. Research indicates that common complications after spinal fusion surgery include the femoral cutaneous neuropraxia, foot drop, hypersensitivity in the lateral thigh, numbness, tingling, and thigh dysesthesia” (Nunley, et al, 3). S. had a neurologic complication after the surgery that affected his bowel and bladder (B&B) function, which required catheterization.
The research on similar spinal fusion surgeries reflects very little evidence of this type of neurologic complication and suggests that the “immediate postoperative neurologic complications” are transient in their nature and will resolve by 24 months with the “rate from 11 down to 2 percent” (Nunley, et al, 3). The arreflexive B&B can be resent if “the sacral reflex arc is disrupted due to the damage of the S2-S4 sacral cord during the spinal cord lesion or when the cauda equina is injured” (Freeman Sommers, 369,376).
Since the site of the operation is much higher than the actual B&B control innervations, the PTA suggested that this presentation could be due to the postoperative swelling around the area that compresses the nerves located below. He explained that neurological return rate is high because the cauda equina region is less sensitive to the trauma than the spinal cord.
The first physical therapy interventions included the basic ostoperative exercises such as ankle pumps, short arc quad and hip adductor/abductor strengthening exercises with a ball and Theraband. The PTA, who had undergone similar surgery in the past, emphasized the importance of the core strengthening program, which is the key to spinal stability. The patient was instructed in isometric abdominal bracing exercises and was taught basic core stability principles. “Poor outcome after a disc surgery has been attributed to loss of multifidus muscle.
A randomized control trial compared the effects of four weeks of isometric exercises for the transverses abdominis together with ultifidus with the effect of gradually returning to normal activities as tolerated in a group of patients with low back pain and found that although both groups symptoms significantly decreased, the group that did not perform the exercises was 12. 4 times more likely to experience a reccurence of back pain at 1 year” (Cameron, 182). It is important to note the socioeconomic issues and the psycho emotional stability of the patient after the surgery.
Motivation for progress is the key to successful rehabilitation – the recovery time from spinal arthrodesis is a long term process and requires patience and sense of purpose. This is mentioned because patient appeared to lack motivation regarding his recovery. This type of withdrawal response may be present not only because of physical disability and its’ complications, but also due to patients emotional fluctuations and coping during certain stages of adjustment to disability (Sisto et al, 106). “Fear of incontinence can result in withdrawal from social activities and isolation.. Patients may resist learning how to perform catheterization technique independently and find it difficult to have family members learn how to assist them” (Sisto et al, 108).
The recent research on pain management in fearful patients ho undergone lumbar spine surgery suggests “the use and effectiveness of cognitive-behavioral based physical therapy interventions” (Archer et al, 1135). It is based on the use of “empirically supported behavioral self-management, problem solving, cognitive restructuring, and relaxation training” that targets the psychosocial risk factors and has a potential to decrease pain and disability (Archer et al, 1133).
Patient’s decreased desire to participate changed after his family visit. Moreover, the PTA’s personal familiarity with fusion surgery and excellent results achieved inspired the patient to adhere to the ehabilitation requirements. Next week’s physical therapy session revealed the gait deficit that was presented by insufficient push off gait pattern due to dorsiflexor weakness and plantar flexors tightness. The patient was able to stand and walk with a rolling walker; however, the right leg was still weak and the exercises such as weight shifts that target the balance were not resulting in progress.
S. also had no tolerance to stretch of right hamstring- the patient responded with withdrawal reaction and complained of pain upon therapists attempt to stretch his left hamstring. This reaction could be aused by pain due to the excursion of inflamed sciatic nerve down the leg. Similar response therapist can observe in straight leg raise test to diagnose potential “involvement of lumbosacral nerve roots” and damage to the sciatic nerve when “the nerve is maximally elongated down the posterior aspect of the thigh” (Cameron, 165).
The general plan of care (POC) for this patient included the basic program of postoperative strengthening and gait training with balance regain. S. was performing marches, toe raises, weight shifts, and hip standing gluteus medius/maximus strengthening exercises. The goal of he physical therapy was to reduce pain, regain normal trunk range of motion, normal lower extremity and abdominal strength. The ability to progress to outpatient rehabilitation to return to activities of daily living was the main goal.
To prepare for hospital discharge the patient was working on bed mobility, transfers, gait training on levels and stairs, postural correction, symmetry and awareness. “The plan of care is directed toward techniques that target the mechanical disfunctions identified during the examination” (Cameron, 174). This type of discharge goals are the baseline of the spinal rehabilitation with the urpose to discharge in timely manner. The POC did not address the necessity of psychological support for patients who lack motivation; however, it is mutually un scene of physical therapy intervention.
The new approaches suggest the involvement of both physical and psychological erstood behind the interventions to improve the spinal surgery outcomes. One of the trials regarding the interventions based on cognitive- behavioral techniques and physical activity goal settings is still in progress and investigates post-operative functioning after patients received a pre-surgical physiotherapeutic prehabilitation program (Lotzke, et al, 3).
