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Pilates for Lumbar Spinal Fusion:

Recommended Conditioning for Multilevel Spinal Fusion Rehab

Maggie Curcio

October 14, 2012

Summer 2012 - Chicago

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Abstract

This paper focuses on a suggested rehabilitative and ongoing conditioning program for

first twelve months for patients who have undergone single or multilevel lumbar spinal

fusion surgeries. Since 1996, the number of spinal fusion surgeries in the United States

has increased as much as 116% and has become one of the most increased of

orthopedic surgeries over the past fifteen years (Take Care of Your Health After Spinal

Fusion, 2011). However, while spinal fusion may relieve a patient of acute pain,

underlying issues (poor posture, sacroiliac joint instability, weak abdominal or back

extensor muscles, and limited hip or thoracic rotational movement) still persist and can

cause long term pain if not treated properly. The focus of this paper will include

suggested post-operative conditioning during the first 90 days as well as during 3-6, 6-9,

and 9-12 months and beyond. Many of these recommendations can be instituted with

patients as a preventative measure as well.

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Table of Contents

1. Anatomical Description and Spondylolithesis

2. Case Overview

3. 2-3 Months Post-Surgery: Physical Therapy

4. 3-12 Month Conditioning Recommendations

5. Conclusion

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Anatomical Description of the Lumbar Spine

The human spine is made up of 33 vertebrae including 7 cervical, 12 thoracic, 5

lumbar and 3-5 sacral and 4 coccygeal as well as of bony elements, flexible ligaments,

tendons, muscles, and nerves (Isacowitz, 2008). In between these vertebrae are 23

intervertebral discs which act as a “cushion” to provide to allow slight movement of the

vertebrae and acts as a ligament to hold the vertebrae together (sacral and coccygeal

segments of the spine do not consist of intervertebral discs as they are naturally fused

segments). (Wikipedia, 2012). In addition, the lumbar spine is designed to be incredibly

strong to protect the highly sensitive spinal cord and spinal nerve roots while remaining

flexible to provide for mobility in many different planes (including flexion, extension,

lateral, and rotation). An image depicting the spine (with focus on the lumbar region) is

below.

Spondylolithesis

A back condition that is common to the lumbar spine is called spondylolisthesis

which occurs when one vertebra slips forward on the adjacent vertebrae. This will

produce both a gradual deformity of the lower spine as well as a narrowing of the

vertebral canal (Barr KP, 2005). Spondylolisthesis is graded according to the amount

that one vertebral body has slipped forward on another. A grade I slip means that the

upper vertebra has slipped forward less than 25 percent of the total width of the

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vertebral body, a grade II slip is between 25 and 50 percent, a grade III slip between 50

and 75 percent, a grade IV slip is more than 75 percent, and in the case of a grade V

slip, the upper vertebral body has slid all the way forward off the front of the lower

vertebral body (Take Care of Your Health After Spinal Fusion, 2011). Spondylolisthesis

with the slippage greater than 50 percent of the width of the adjacent vertebral body

generally requires a spinal fusion to stop further slippage and provide relief from the

associated symptoms of instability and nerve root irritation (Parker SL, 2012). Causes of

spondylolithesis typically include injuries or congenital defects that progress over time.

Many patients with spondylolisthesis will have vague symptoms and very little

visible deformity. Often, the first physical sign of spondylolisthesis is tightness of the

hamstring muscles in the legs. Only when the slip reaches more than 50 percent of the

width of the vertebral body will there begin to be a visible deformity of the spine and

often there may be a dimple at the site of the abnormality. Sometimes there are mild

muscle spasms and usually some local tenderness can be felt in the area. Range of

motion is often not affected, but some pain can be expected.

In a recent study conducted on patients with degenerative lumbar

spondylolithesis, nearly 54% of patients eventually required surgical management due

to lack of improvement (pain, disability, quality of life, depression, general health not

improved over a 2-year period). Additionally, costs were estimated at nearly $10,000

USD without improvement for comprehensive medical management during a two-year

period (Parker SL, 2012).

Case Overview

Patient was a 37 year old female suffering from lumbar general disk disease,

degenerative isthmic spondylolisthesis at the L4 (Grade II), and subsequent bilateral

lumbar radiculopathy. She had extensive conservative care without improvement

including physical therapy, chiropractic care, attempted facet joint injections, and pain

medication. Posterior spinal fusion at the L3-L5 was recommended as next course of

action. During the course of her surgery, the L5-S1 disk space was evaluated and was

noted to be severely vertical and it was determined at this point to include this level in

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the fusion in order to allow for better stability and reduction in the spondylolisthesis

segment.

Immediate post-surgical treatment (48 hours post-surgery) included sitting,

standing, short walks and practice of daily activities (e.g. getting in and out of a car,

stairs, laying down and getting up, etc.). Patient was instructed to restrict all activities

beyond this for first two weeks post operation. Upon clearance at two weeks, patient

was instructed to increase daily walking activity to 20-30 minutes per day and sitting up

to 60-90 minutes per day. At 6-8 weeks post-surgery, the patient was instructed to begin

physical therapy and at 12 weeks post-surgery the patient was cleared for select low-

impact exercise (e.g. walking, elliptical) as well as light weight-bearing exercise (under

10 lbs.).

The initial goal of a physical therapy program was to increase spinal and trunk

stability. Since spinal stability consists of three key areas: bone and ligamentous

structures, muscular systems that surround the spine, and neural control system that

coordinates muscle activity , endurance of the muscular systems was more important

than the muscle strength (Barr KP, 2005). A focus on key back muscles including

spinal extensors, trunk flexors and pelvic stabilizers was the initial focus on the therapy.

Once muscular stability and endurance was increased, the focus shifted to

increasing mobility (particularly in the thoracic region) and strength (particularly in the

pelvic, trunk and back muscle systems). Given that the spine was essentially now fused

from L3 downward (as sacral and coccygeal vertebrae are already naturally fused),

mobility of the lower spine was extremely limited and care was given to determining a

program that was sustainable and allowed for increased strength and mobility in the

non-fused sections of the spine as they would be susceptible to increased risk of disc

and spinal conditions in the future.

2-3 Months Post-Surgery: Physical Therapy

Initial physical therapy included gentle stretching and basic pelvic and trunk

stabilization exercises. Flexion, extension and rotational exercises of the back and trunk

were restricted. In addition, extra focus was given to hip extensor (particularly

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hamstrings) and dorsal flexor (calf) stretching as muscles were extremely tight. The

following exercises were used 3-4 times per week.

1. Abdominals/Pelvic Stabilization:

a. Abdominal Contraction: Lying in prone position with knees bent, contract

abdominals and squeeze ribs down. Hold for 5 seconds. Relax and

repeat 10 times.

b. Supine Posterior Tilt: including contraction of Kegal muscles to increase

pelvic stabilization. This increased to small pelvic curls as patient gained

strength back.

2. Calf Stretch: Standing on calf stretch apparatus or stair, dorsi flex foot while

keeping other foot straight. Increased to standing on flat surface and conducting

as heel raise.

3. Hip Extensors:

a. Hamstring Stretch with resistance band: Lying prone with one knee bent

and one foot dorsi flexed in resistance band. Slowly straighten knee into

perpendicular position to increase stretch. Hold for 20 seconds, relax and

repeat 5 times on each side.

b. Piriformis Stretch: Lie on back with both knees bent. Cross one leg on top

of the other. Pull opposite knee to chest until a stretch is felt in the

buttock/hip area. Hold 20 seconds. Relax. Repeat 5 times each side.

4. Hip Adductors:

a. With resistance band around both feet, walk sideways in small steps until

resistance is felt. Continue for 5-7 minutes on each side to increase hip

adductor strength and stability.

b. Clam: Lie on one side with lower arm bent under head and upper arm

resting with hand on floor near chest. Bend both knees and flex hips to

approximately 45 degrees and find neutral spine position. Slowly raise

upper leg 8 to 10 inches and lower while keeping heels together. Do 5 to

10 repetitions and repeat on opposite side.

5. Balance/Trunk Stability:

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a. Wobble Board: Stand on wobble board with support for 30 second

increments.

b. Pilates Ball: Sit on Pilates ball with therapist gently pushing side to side.

3-12 Month: Conditioning Recommendations

3-6 Month Post Surgery: Additional Physical Therapy and Light Exercise

After 3 months, the patient was cleared for low-impact aerobic exercise for longer

periods (e.g. 30-60 minutes of brisk walking, elliptical machine, etc.). Biking, swimming,

running or any high-impact activities were still restricted until the six month mark.

Additional physical therapy, seated massage, and/or fundamental-level Pilates were

recommended with restrictions still around flexion/extension and spinal articulation of

any sort. From a BASI Block System perspective, I would recommend beginner

exercises (based on strength of patient) with a focus on trunk and pelvic lumbar

stability.

6 -12 Months

After a patient has demonstrated improvement in both pelvic lumbar stability as

well as increased strength in abdominals, back extensors, and hip flexors, I would

recommend increasing the challenge of both mat and equipment to include additional

intermediate level exercises. Focus should continue on building pelvic stabilization as

well as on increasing flexibility of both hip flexors/extensors, gaining more spinal and

thoracic mobility, and advancing to more challenges range of motion exercises.

12 Months +

After one year and doctor clearance, patients should be allowed to take on more

challenging and advanced Pilates repertoire based on their own strength and capability.

Care should still be given to spinal articulation exercises and anything that may create

contraindication for the lower lumbar spine. In addition, movement and exercises that

increase thoracic mobility should be a key factor in the design of any program. Regular

inclusion of the Step Barrel as well as thoracic stretch and spinal mobility exercises

should be considered.

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Recommended Pilates Mat and Auxiliary Workouts

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Recommended Pilates Equipment Program (3-12 Months)

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Additional Thoughts

Depending upon the nature of the fusion and the ability of the patient, I would

recommend avoiding most spinal articulation exercises until at least a year post-

surgery. In some cases, spinal articulation exercises may need to be permanently

avoided – especially in multi-level fusion surgeries – as they will be contraindicated for

patients. Additionally, I would recommend avoiding exercises with deep lumbar flexion

(e.g. Push Through Series such as Sitting Forward, Sitting Back, etc. on Cadillac,

Monkey on Cadillac, Rowing Series, Climb a Tree and Teaser on Reformer, etc.) as

these will likely be too difficult if not impossible for a client to achieve.

Some spinal articulation exercises may be introduced after a 12-month period

with assists or modification (e.g. Teaser on Cadillac with ball, Neck Pull with cushion,

Tower on Cadillac, etc.); however, these should be done with great care and

consideration of client’s abilities.

Conclusion

Research shows that people suffering from lower back pain have deficits in

spinal proprioception and will make repositioning errors while trying to stay in neutral

spine. There is no correlation with improved proprioception or posture control post-

surgery and in some studies, most people will need more extensive training in posture and exercise positioning because their ability to reproduce precise movements reliably is reduced (Barr KP, 2005). As a result, spinal fusion

rehabilitative care can benefit greatly from inclusion of an ongoing, lifetime Pilates

conditioning program as it will help to extend and improve upon movement, mobility,

balance, ROM and strength learned in physical therapy

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References

1. Team Pilates – Pilates Consult blog “Specific Exercises for Scoliosis and a

Spinal Fusion” (Angelie Meizer) November 14, 2010

2. Pilates for Fragile Backs – Recovering strength after surgery, injury, or other

back problems (Pilates for Fragile Backs)

3. Comprehensive Medical Management of Lumbar Stenosis and Spondylolithesis

is not Effective in Real-World Care: A Value Analysis of Cost, Pain, Disability

and Quality of Life. Neurosurgery. 2012 August; 71(2):e554-5. Authors: Parkers

SL, Zuckerman S, Shau D, Mendenhal S, Godil SS, McGirt M.

4. Lumbar Stabilization Core Concepts and Literature, Part I. American Journal of

Physical Medicine & Rehabilitation. 2005;84:473-480. Authors: Barr KP, Griggs

M, Cadby T.

5. Study Guide – Comprehensive Program. Body Arts and Science International.

2008. Author: Rael Isacowitz.