The first step in recovery after a spinal injury or surgery is to determine the “root cause” of the problem. Often spinal injuries are the result of years of poor movement patterns. Many patients present with similar patterns of movements and postures that, left uncorrected, will not only lead to acute injuries but will also cause chronic pain and deterioration of the lumbar spine.^1,2

A history and comprehensive physical examination are the first steps in addressing the “root cause.” The history is used to help determine whether the problem is acute or long term. If the patient complains of back pain that is more local to a specific area, a facet joint could be the problem. If a patient complains of pain that is more “beltlike,” the problem could be more muscular in nature. If the patient complains of leg, buttock, or thigh pain that “shoots or radiates,” the problem is more likely to involve the neurologic structures of the spine. If the patient wakes up in the morning feeling stiff and sore and the pain is alleviated with movement, it is more likely to be muscular or arthritic in origin. Conversely, if a patient wakes up feeling better and experiences more pain as the day goes by, especially in the buttocks and legs, the pain is usually neurogenic in nature.

The physical examination is used to evaluate the patient’s movement patterns. Basic biomechanics dictate human beings are designed to ambulate and move primarily from the hips, knees, and ankles rather than the lumbar spine. The spine is meant for cushioning, shock absorption, and stability. In many cases, because of rapid growth in the younger population or lack of general exercise in older patients, the hip flexors and hamstrings become tight. The gluteal muscles and abdominal muscles become weak, and the individual loses the ability to move normally. When this happens, hip, knee, and ankle motion are limited, and the spine is forced into a resting position of hyperextension (Figure 3-1). As this occurs, hip motion is substituted by excessive motion at the lumbar spine, which puts significant pressure on the facet joints and disks, leading to facet and disk pathology. A simple gait analysis will reveal typical patterns seen in patients with low back pathology. They often demonstrate loss of true heel strike caused by a tight gastroc and soleus. The legs are externally rotated because of tight hip flexors and rotators and weakness in the gluteal muscles. The patients pull themselves along using the hamstrings rather than pushing themselves forward by using the gluteal muscles and extending the hips. The pelvis is maintained in an anterior tilt because of a lack of abdominal strength, tight hip flexors, and weak gluteal muscles. In turn, the lumbar spine is

in a position of extreme hyperextension, locking the facet joints and overloading the posterior aspect of the disk.

Range of motion (ROM) measurements are taken to determine the patient’s basic flexibility. When assessing flexibility, care must be taken to maintain a neutral spine throughout the examination. A modified straight-leg raise is used to test the hamstrings. Results greater than 15° of short of neutral indicates a positive test result. The quadriceps are compared from a supine position (heel to buttock) to a prone position. Any discrepancies between the two positions indicates tightness in the quadriceps. The patient’s hip flexors should be assessed using the Thomas test. Motion less than 5° below neutral is indicative of a positive test result. The hip rotators and piriformis are tested in supine with the hip flexed to 50° to determine their length. Normally, the hip should rotate at least 30° and adduct 40° for a normal test result. The Obers test is performed in the sidelying position to test the length of the iliotibial band and tensor fascia latae. Normally, the hip should adduct to 45° with the knee straight without rotating the spine.

The next step in the physical examination is the manual muscle test. Close attention should be paid to the strength of the hip flexors, gluteal muscles, hamstrings, and abdominals. The gluteal muscles should be tested as both hip external rotators and hip extensors.

The rehabilitation program is a system of exercises that produces functional movement patterns and coordinated core strength for the hips, abdominal muscles, and low back muscles. Athletic functions such as throwing, swinging, and lifting, as well as activities of daily living require normal movement patterns and coordinated muscle strength to achieve maximum performance while protecting the spine. Lumbar spine rehabilitation begins with establishment of pain-free neutral position. Balance and coordination are added into the program with endurance exercises. By building endurance strength centered on a neutral pain-free position, postinjury and postsurgical rehabilitation can begin relatively early because it avoids extreme and painful ROMs.

The rehabilitation program is a five-level program that gradually increases in strength, endurance, and proprioceptive demands (Table 3-1, on page 24). Level 1 starts in a neutral pain-free position with specific stretching exercises for the legs and hips and isometric exercises that train the core muscles to protect the spine (Figure 3-2). In the acute postoperative period, motion through the spine can cause mechanical trauma and exacerbate symptoms. Patients are taught to strictly maintain a neutral pain-free position while performing the basic stretching and core stabilization exercises (Figure 3-3).¹ The program accelerates to increasing intensity and compromised positions with balance and coordination exercises
as long as the patient is able to maintain a pain-free state (Figure 3-4). If a particular exercise exacerbates symptoms, then exercise is modified, decreased, or discontinued.

Almost every postoperative patient is encouraged to ambulate immediately after surgery. The goal is to walk several times a day for a comfortable distance. Postsurgical rehabilitation is initiated when soft tissues have adequately healed, symptoms have sufficiently stabilized, and the stability of the anatomic structures is acceptable. Typically, a physical therapy program that focuses on a stretching program with a neutral spine can be started 2 to 4 weeks after a single level lumbar laminotomy or discectomy, 6 to 8 weeks after a multilevel laminotomy or laminectomy, 6 to 8 weeks after an artificial disk replacement, and 6 to 12 weeks after a fusion. Restoring normal mobility in the ankles, knees and hips while maintaining a neutral spine will help reduce mechanical stress from the bony and muscular structures of the lumbar spine. This in turn will help reduce pain and improve function in a timely manner.³

The stretching portion of the program can begin as soon as the surgical incisions are healed, typically 14 to 21 days after surgery. The stretching exercises are all performed in a neutral spine position slowly and deliberately without pain to protect the healing tissue. Each stretch is held for 10 full seconds and repeated 7 to 10 times twice day. The stretching portion of the program will be maintained throughout the entire rehabilitation process and continue after discharge.

To properly stretch the muscles of calf, the stretch is performed in the standing position without shoes. Care is taken so the lumbar spine is not allowed to fall into a position of hyperextension. The patient stands with his or her hands on the wall and slowly bends at the elbows and ankles while the heels stay firmly planted on the ground. This ensures that the motion takes place at the ankle and not the arch of foot. The spine stays neutral throughout.