Is physical therapy needed after lumbar fusion? Well, it depends….

I was just asked again over the weekend from a friend of mine who had a one level lumbar spine fusion if PT is needed after surgery to help with recovery.  I asked him what his doctor had advised him and his reply from his surgeon was  “well, I don’t think you need PT, just don’t bend, twist, lift, or do anything beyond walking and you should be fine in time”.

The problem with this advise is that what happens when you want to resume a normal life that involves all sorts of lifting, bending, and maybe even a return to sports?  Ever try to get through your day without lifting, bending, carrying, etc?  Not too easy.

In my opinion, yes, he very definitely needs the services of a physical therapist to help him maximize his recovery.  Now, let me say a few things in defense of the surgeon:  the reason he advised his post surgical patient to not seek PT is probably because of the feedback he has received from other patients that have had PT treatment after surgery “well, they massaged the tissue and scar for awhile, then ultrasounded it ,then put some electrodes on there with ice for 20 minutes and gave me a few exercises to do.  It wasn’t all that helpful and so I stopped going”. Passive modalities and generic “back” exercises are worthless in the long run and do not lead to lasting changes. PTs who provide this type of therapy are doing their patients a disservice.

Here’s what I told my friend:  The first question you need to ask yourself is why did I rupture a disc in the first place?  When we lose mobility in an area due to stiffness, we will “re-gain” that movement somewhere else, usually in the least desirable area.  Most manual therapists will tell you that the thoracic spine and rib cage becomes very stiff and hypo-mobile in many patients with chronic lower back pain.  Different parts of our spine have different affinities for movement:  the lumbar spine can rotate, but really likes to flex forward and extend backwards.  The thoracic spine can flex and extend, but mainly likes to rotate.  This relationship works great since everyone is doing what they really like to do, until the thoracic spine becomes tight and stops rotating as well………

Now, many things contribute to the thoracic spine becoming tight and that’s a discussion for another time (probably how your sitting reading this is a big contributor).  However, now you have a situation where the thoracic spine isn’t rotating all that well, but the body still requires rotation to occur for almost all basic functions, including walking.  Guess what? Now we call up the lumbar spine and ask it to not only flex and extend, but “can you rotate as well too?”  For awhile, things are good until your hip becomes tight and stops moving as well as it once did (notice how it seems a bit harder to get those socks on as we age).  Now, the only place you have to get any motion is the lumbar spine.  After time, the lumbar spine develops an instability due to the constant movement and becomes an area of pain.  The surgical solution is fusion, but now you’ve fused the only place the body had left to get some  movement…are you beginning to see the long term problems with this?  It is common knowledge that the disc area above and below the fusion site is more susceptible to herniation and rupture in the future.  Now you know why.

The role of Physical Therapy in the management of post lumbar fusion rehab is NOT to ultrasound and e-stim the area, but to perform a movement analysis of the entire spine to determine areas of restriction and to then restore “normal” movement in the area.  In my experience, this usually involves treatment of the thoracic spine and ribs to improve overall mobility regardless of the painful area.  Then the patient needs to be taught  how to move smarter and create new movement patterns in order to avoid movements and postures that will  increase loads on the lumbar spine. Finally, we need to strengthen our entire body.  Notice I said our entire body not just our “back” since the body moves as one functional unit.

The lumbar spine is under a tremendous amount of load and getting the rest of the body to share the load is the best thing you can do for a healthy back.

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