(PSSR)Training Certificate Program Post Surgical Spine...

Post Surgical Spine Rehabilitation (PSSR)Training Certificate ProgramOverviewAnthony Gross, DC, CCSP, FIAMA – Consult Physician, Laser Spine Institute2016 Annual Professional Baseball Chiropractic Society Conference: Scottsdale, AZ

The Following Presentation:

▪ Is an abbreviated overview of the complete 12 hour Post Surgical Spine Rehab Program scheduled throughout 2015 at LSI surgical centers in Tampa, Scottsdale, Philadelphia, Oklahoma City, Cleveland, Cincinnati and St. Louis

▪ Register at: www.acatoday.org

When conservative care is exhausted and for certain patient presentations where surgical intervention of the spine is indicated, the

American Chiropractic Association supports minimally invasive approaches such as those used by Laser Spine Institute

Laser Spine Institute is the leader in minimally-invasive spine surgery and provides a more effective alternative to open neck and back surgery.

Through minimally-invasive spine surgery, LSI is expanding health care options for patients and is helping them achieve a better quality of life.

ACA & Laser Spine Institute

Patients First

• Focuses on cooperative multidisciplinary continuum of care

• In-depth post-surgical spine rehab instruction

• Intergrative patient-centric quality treatment and care

• 12 Hour course, optional exam preferred resource ACA/LSI

• Joint cooperative program: ACA, ACA Rehab, LSI

ACAFounded in 1964 and representing over 130,000 doctors of chiropractic, chiropractic assistants and students, ACA is the largest association committed to the highest clinical and ethical standards, freedom of choice of healthcare providers and the pursuit of optimal health for their patients.

Laser Spine Institute

Originated in 1988 as the Chiropractic Rehabilitative Association (CRA)

Diplomates (DACRBs) in over 35 states and 3 Canadian Provinces

ACA Rehab Council

Co-founded by Michael Perry, MD and James St. Louis, DO in March 2005

Locations in Tampa, FL, Oklahoma City, OK, Philadelphia, PA , Scottsdale, AZ, Cleveland, OH, Cincinnati, OH, and St. Louis, MO.

AAAHC-accredited (Accreditation Association for Ambulatory Health Care, Inc.)

Strategic partner with ACA

Meet the Trainers

Anthony A. Gross, DC, CCSP, FIAMA Consult Physician

Certified Chiropractic Sports Physician Clinical Educator and Consultation Physician Laser Spine Institute, Scottsdale, Arizona Past President Arizona Association of Chiropractic Founding Member AAC Sports Council Fellow – International Academy of Medical Acupuncture (FIAMA)

George Petruska, DC, DACRB

Past President ACA Rehab Council Vice President and Co-founder American Board of Chiropractic Specialties (ABCS) Consultant American Chiropractic Rehabilitation Board (ACRB) Co-founder ACA Council on Physiological Therapeutics and Rehabilitation (CCPTR) Co-authored Bylaws, Standards, Policies and Procedures for the ACRB and the CCPTR including establishing protocols for writing test questions Post-graduate and post-doctoral faculty

Jerrold J. Simon, DC, DACBN, DACRB, DABDA, DIBE

President of ACA Rehab Council Past President of the ACA Nutrition Council Vice President of the IBE (International Board of Electrodiagnosis) Vice President of the OSCA (Ohio State Chiropractic Association) Past President and Co-Founder of the ABCS (American Board of Chiropractic Specialties) Post Graduate and Post Doctoral faculty

Overview Agenda

• Understanding pain generators & the continuum of care for spine related disorders

• Define pathology-specific treatment paradigms• Develop diagnostic recognition of surgical

candidates• Indications for and types of spine surgery• Understanding and co-management of the

recovering post surgical patient• Returning to Activities of Daily Living (ADLs)• Brief intro to post surgical rehabilitation and

treatment modality considerations

The Agenda – Full 2 Day Program

DAY 1 • Part 1: Perioperative Care & the Doctor of Chiropractic

– Recognizing Surgical Candidacy & Surgical Options• Part 2: Medical Clearance DAY 2• Part 3: Rehabilitation Methodology

– Rehab Theory and Science– FCE – what is it and why is it so important– PSSR protocols (Hands On)

• Part 4: Post-Training Exam

The “Problem”“As long as man, the biped, continues to stand erect &

upright on his two feet, he will suffer from the stress imposed on his lumbar spine.”

Dr. Joseph Janse, President, NUHS (1945–1983)

Consider the Stats…

• 31 million Americans experience low-back pain at any given time.1 • Low back pain is the single leading cause of disability worldwide,

according to the Global Burden of Disease 2010. One ½ of all working Americans admit to having back pain symptoms each year.2

• Back pain is one of the most common reasons for missed work. In fact, back pain is the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.

1 Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116Vallfors 2 Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98. 2 Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98. 11

More Stats…• Most cases of back pain are mechanical or non-organic—meaning they are

not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.

• Americans spend at least $50 billion each year on back pain—and that’s just for the more easily identified costs.3

• Experts estimate that as many as 80% of the population will experience a back problem at some time in our lives.4

• The incidence of low back pain increases faster than that of any other ailment of mankind.5

3This total represents only the more readily identifiable costs for medical care, workers compensation payments and time lost from work. It does not include costs associated with lost personal income due to acquired physical limitation resulting from a back problem and lost employer productivity due to employee medical absence. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD. 4Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98 5Medical Bulletin, April 21, 1981. Globe International Group. Box 21, Rouses Point, NY, 12979.

PART 1Perioperative Care & the Doctor of Chiropractic

PERIOPERATIVE

Definition: Perioperative is the time period that includes the three major phases of surgery.

1) The initial phase, the preoperative phase, lasts from the decision to have surgery until the beginning of surgery

2) The second phase is the surgery itself3) The final phase, the postoperative period, is the time after

surgery until recovery is completePerioperative, including all three phases, can last for days, weeks or months

Continuum of Care

• Transitioning from conservative care to non-conservative care

• Perception of pain (differentiation)

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Therapeutic Efficacy Studies

• Pain generators and outcome predictions– Quality of pain linked to type of pain generator– Pain generator can help the provider determine the course of

care and modalities to provide and can help to better predict the outcome for that particular patient

– Set proper expectations with the patient to build trust

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Pain Introduction

• Local vs. central perception of pain• Pain generators (importance of differentiation)

Pain Generators• Pathomechanical• Inflammatory

– chronic/acute• Compressive

– discogenic/neurogenic• Soft Tissue Mediated

– Spasm/splinting• Neuropathic

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Pathology Introduction

• Types of pathology– Degenerative disorders of the spine

• IVD• Stenosis• Facet

– Failed Back Surgery Syndrome– Spinal Instability

Degenerative Disorders of the Spine

• Pathogenesis– Can be attributed to morphological changes that affect

the integrity of the axial skeleton

Degenerative Disorders of the Spine

• Aging process of the IVD– IVD– Cartilaginous end plate– Apophyseal joints– Ligamentous changes– Calcification/osteophytes

IVD Pathologies

• DDD• Annular Tears• Bulge/protrusion/herniation• Discitis

Stenosis

• Foraminal stenosis• Spinal canal stenosis• Lateral recess stenosis• Constellation of stenotic

components

Zones of Compression

Case Study – HNP Paramedian Extrusion

Arthritic Facets – Axial T2 L/S MRI

Failed Back Surgery Syndrome (FBSS)

• Demographic statistics• Postoperative Epidural Fibrosis• Adjacent level

Instability/Degeneration up to 18.5% (L/S)

Anterior cervical decompression and fusion accelerates adjacent segment degeneration: comparison with asymptomatic volunteers in a ten-year magnetic resonance imaging follow-up study. Matsumoto, M., Okada, E., Ichihara, D., Watanabe, K., Chiba, K., Toyama, Y., ... &

Hashimoto, T. (2010). Spine,35(1), 36-43. Adjacent Segment Disease after Lumbar or Lumbosacral Fusion: Review of the LiteraturePark, Paul; Garton, Hugh J.; Gala, Vishal C.; Hoff, Julian T.; McGillicuddy, John E. Spine. 29(17):1938-1944, September 1, 2004.

Spinal Instability • Spondylolisthesis

– Isthmic (Spondylolysis/Pars)

– Degenerative

– Iatrogenic

• Grade implications

– stable vs. unstable

– imaging considerations (dynamic x-ray & MRI)

• Transitional anatomy

**Per Yochum –NO documented case of a CONGENITAL SPONDYLOLYSIS in the literature**

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Non Surgical Pain ManagementJust as Surgical interventions can range from minimally invasive needle incisions to large open procedures with extensive hardware, there also is a continuum on non-operative spine care management • Rest • At home exercises/stretches • Massage • PT • Chiropractic (CMT, MT, LLLT, Decompression) • Acupuncture • Oral Meds (OTC – Rx) • ESI, Nerve Blocks Below can be considered a surgical procedures – performed by pain management specialists

• RFAs• Spinal Stimulator Implants

Surgical Intervention

• Spinal Cord Stimulator • Vertebroplasty/Kyphoplasty • Minimally Invasive Spine Surgery (MISS) • Discectomy • Laminectomy • Arthrodesis • Fusion

Epidural Steroid Injections - ESI

The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surg Am. 2012 Aug 1;94(15):1353-8. doi: 10.2106/JBJS.K.00341. Radcliff K, Hilibrand A, Lurie JD et al

METHODS: 154 ESI group compared with 453 NO – ESI Group

CONCLUSIONS: Lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection

Red Flags• Progressive neurologic deficit

– Cauda equina syndrome – foot drop, bowel or bladder dysfunction, saddle anesthesia, reflex changes

• Traumatic injury/cumulative trauma –r/o fracture • Insidious onset • Immune suppression: steroid use, IV drug, HIV • Age of onset over 50 • Osteoporosis/compression fracture • Cancer history • Diabetes • No relief at bedtime or worsens when supine • Constitutional symptoms (e.g. fever, weight loss) • History of recent infection/illness • Previous recent surgery *Univ. of Michigan Health System – Guidelines for Clinical Care, 1/2010

Conclusions

• Understanding care thresholds– Cauda Equina syndrome

• Altered sensation • Severe or progressive weakness or numbness in the lower

extremities • Difficultly walking/balance issues • Saddle anesthesia • Bowel/bladder control, ED

• Promoting interdisciplinary cooperation

Indications for and Types of Spine Surgery

Overview• History of spine surgery

• Indications for spine surgery

• Minimally invasive spine surgery– Endoscopic, non-fusion

• Laminotomy

• ForaminotomyCombination of above will be referred to as “LFD” – (Laminotomy, Foraminotomy and Decompression of the Nerve Root)

• DTAs (Destruction by Thermal Ablation) – similar to rhizotomy

– Fusion (MIS – Minimally Invasive Stabilization)

– Motion Sparing Procedures• Arthrodesis/Disc Replacement/Dynesys

• Coflex

– Regenerative Medicine Procedures

– Kyphoplasty/Vertebroplasty

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Surgery

• Inpatient vs. outpatient• Fusion vs. non-fusion• Traditional vs. minimally invasive spine surgery (MISS)

Indications for Surgery

• Failed conservative treatment (at least 90 days)– Chiropractic care– Pharmacotherapy– Pain management– Physical therapy– Acupuncture

Spinal decompression-traction – do not confuse providers with surgical decompression

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Traditional Laminectomy and Fusion

Minimally Invasive Spine Surgery

Minimally Invasive Spine Surgery

• Maximum preservation of structure and function of the spine

• Minimal disruption to musculature • Can be performed under local and IV sedation • Less complications • Quicker recovery • Less expensive • Less scar tissue formation

Minimally Invasive Spine Surgery Advantages

Minimally invasive procedures

Traditional open neck and back surgery

Hospital stay Outpatient 2-5 days

Infection rate 0.13% Up to 4.7%

Complication rate 4% 31%

Muscle disruption Small incision, muscle sparing, muscles separated Muscles cut, torn

Minimally Invasive Endoscopic (Non-Fusion)

• Lumbar and cervical – Laminotomy – Foraminotomy – Endoscopic Discectomy – Laser DTA

Microscopic Surgery

Laminotomy

Indications • Spinal stenosis • Herniations • Foraminal stenosis • Spondylolisthesis (stable - less than 5 mm shift)Limitations • Typically one level performed* • Steep learning curve • C3-4 highest level • Prior posterior C/S surgery

MISS-Laminotomy

Before surgery After surgery

MISS-Foraminotomy

• Indications – Foraminal stenosis related to: – Bone spurs – Bulge/herniation – Scar – Synovial cyst

• Limitations – Typically one level – Not able to do contralateral side

Endoscopic Discectomy

Facet Thermal Ablation

Minimally Invasive Stabilization (MIS)

Used in treating:• Central cervical herniated discs• Multi-level spinal stenosis• Clinical instability• Spodylolisthesis• Swelling of the spinal cord

(myelomalacia)

Lumbar Fusion

• PLIF• TLIF• XLIF/DLIF• AXIA LIF

Cervical

• ACDF

Extreme Lateral Interbody Fusion XLIF/DLIF/LLIF

Indications• Degenerative disc disease• Spondylolisthesis• Degenerative scoliosis

Limitations• Limited to upper lumbar region• Severe degenerative spondylolisthesis• Must be backed up w/posterior instrumentation• 25% risk of transit pain or paresthesias in thigh or groin

Decompression with Interlaminar Stabilization

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Indications• Spinal stenosis• Foraminal stenosis

Limitations• Cautious osteoporosis• Increased risk for spondy

dislodging

Disc Replacement - Arthrodesis

Used in treating:• Degenerative disc disease• Designed to maintain motion

The Mobi C Cervical Disc, manufactured by LDR Medical

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Dynamic Stabilization• Dynesys Dynamic Stabilization procedure: Combines spinal fusion with

dynamic stabilization, using flexible materials to stabilize and preserve function.

• Polycarbonate urethane spacers limit spinal extension (BE AWARE OF RADIOLUCENCY DUE TO NO METAL CROSSBAR)

• Polymer cord acts as a tension band to limit spinal flexion • This creates a “dynamic” stability

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Stem Cell Treatment

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Post-surgical guidelines for recovery*

• Walking = 2 hours post surgery

• Golf putting/chipping = 3 weeks

• 15 lb lifting = 6 weeks

*Each patients activity restrictions may vary check with performing surgeon for exact requirements/restrictions.

Precautions, Limitations & Medical Clearance for Rehab

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Medical Conditions to Review for Clearance

• Cardiovascular Disorders• Hypertensive Disorders• Pulmonary Disorders

Categorical Drugs & Their Side Effects

NARCOTIC ANALGESICS

Generic Ingredient Brand Name Use/Action Side Effect

Fentanyl Duragesic Pain CV,BP,P

Merperidine Demerol Sev, Pain BP,P

Morphine Avinza Sev. Pain P

Oxycodone OxyContin Mod. Pain BP,P

(Cardiovascular/CV, Blood Pressure/BP & Pulmonary/P)


ANXIOLYTICS & SEDATIVE HYPNOTICS


Diazepam Valium Anxiety CV, BP

Lorazepam Ativan Anxiety CV



ANTIPSYCHOTICS


Aripipazole Abilify Schizo. BP

Risperidone Risperdal Schizo. CV, BP

Quetiapine Seroquel Schizo. BP

Haloperidol Haldol Psychosis BP


Cardiovascular Disorders

• Abdominal Aortic Aneurysm • Hypertrophic Cardiomyopathy • Congestive Heart Disease • Post Myocardial Infarction • Angina Pectoris (chest px from reduced coronary perfusion)• Post Percutaneous Coronary Intervention • Post Coronary Artery Bypass Surgery (CABG) • Coronary Heart Disease

Cardiovascular Disorders

Review for Clearance• Abdominal Aortic Aneurysm:

– Caution: 4.0 – 5.0 cm in diameter – Greater than 5.0 cm - only rehab after surgical repair

• Hypertrophic Cardiomyopathy – no rehab • Congestive Heart Failure – no rehab • Post Myocardial Infarction – need cardiologist clearance • Angina Pectoris – need cardiologist clearance• Hypertension – need cardiologist clearance

Hypertensive DisordersReview for Clearance

• Stage 1 Hypertension (>140 sys, > 90 dias) – need cardiologist clearance

• Stage 2 Hypertension (>160 sys, >100 dias) – need cardiologist clearance

• Stage 3 Hypertension (>180 sys, >110 dias) – no rehab, refer to cardiologist

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Pulmonary Disorders

Disorder Clearance NeededAllergic Rhinitis Need pulmonologist clearance if complications.

Asthma Need pulmonologist clearance if uncontrolled.

COPD Need pulmonologist clearance if systems of hypoxemia at rest, chronic respiratory failure or cough syncope.

Infectious Respiratory Diseases Normally pulmonologist clearance if symptoms of hypoxemia at rest, chronic respiratory failure or cough syncope.

Cystic Fibrosis Need pulmonologist clearance if symptoms of hypoxemia at rest, chronic respiratory failure or cough syncope.

Pneumothorax Need pulmonologist clearance if symptoms of hypoxemia at rest, chronic respiratory failure or cough syncope.

Drugs with Adverse Pulmonary Side Effects


Fentanyl Duragesic Chr. Pain Hypotension

Merperidine Demerol Severe Pain Hypotension

Oxycodone OxyContin Mod. Pain Hypotension

Phenobarbital Phenobarb. Seizure Hypotension

Pentobarbital Nembutal Insomnia Resp. Dep.

Drugs with Adverse B.P. Side EffectsGeneric Ingredient Brand Name Use/Action Side Effect

▪ Fentanyl Duragesic Chr. Pain Hypotension▪ Merperidine Demerol Sev. Pain Hypotension▪ Oxycodone OxyContin Mod. Pain Hypotension▪ Diazepam Valium Anxiety Hypotension▪ Aripipazole Abilify Schizo. Ortho. Hypo.▪ Resperidone Resperdal Schizo. Ortho. Hypo.▪ Quetiapine Seroquel Schizo. Hypotension▪ Ziprasidone Geodon Schizo. Resp. Disorder

▪

Drugs with Adverse B.P. Side EffectsGeneric Ingredient Brand Name Use/Action Side Effect

▪ Haloperidol Haldol Psychosis Hypotension

▪ Thioridazine Mellaril Schizo. Hypotension

▪ Chlorpromazine Thorazine Psychosis Hypotension

▪ Olanzapine Zyprexa Bipolar Hypotension

▪ Doxepin Adapin Depression Hypotension

▪ Phenobarbital Phenobarb. Seizure Hypotension

▪ Pentobarbital Nembutal Insomnia Resp. Dep.

▪

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Post Surgical Spine Rehabilitation Methodology

Early Stage Rehab Late Stage Rehab

Rehab Entrance Questionnaire

Cardiovascular DiseaseRisk Factor Estimate

Physical Activity Readiness Questionnaire (PAR-Q) & Physician Clearance (bottom half)

Rehab: Informed Consent

Rehabilitation Theory and Treatment Flow Charts

Principles and Skill Development

Quality of Movement>>Quantity of Movement – C. Leibensen

Reactive Neuromuscular Training – Lee Burton, MS, ATC, CSCS

Short term gain into long term adaptation – G. Cook, MSPT, OCS, CSCS

REMEMBER: Dysfunction breeds more dysfunction

Rehab Hierarchy

Function

Stability

Mobility

Rehab Progression

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•Function•Strength•Functionally Integrated Training•Aerobic Training•Endurance•Postural Stabilizers•Outer Core•Inner Core•Mobility

The Functional Exam

Introduction

• Keys To Functional Analysis

• Identify Tight Muscles

• Identify Weak Muscles

• Identify Inhibited Muscles

Functional Exam Guidelines

• Differs from Typical Ortho/Neuro Analysis In that you are looking for:• Imbalances That may be Pain Generators• Crossed Patterns• Facilitated Inhibited Patterns• Sensory-Motor Amnesia & Assoc Postural Alterations• Adaptations, Compensations and Recruitment Patterns• Syndromes That May Have Been Over Looked

Functional Movement Screen• Functional Movement Screen is a system of simple tests designed to

evaluate movement patterns demonstrating asymmetry and deficits.• Every test is an exercise and every exercise is a test• Consist of the Deep Squat, Shoulder Mobility, Shoulder Elevation, Static

Ab Hold, Flex Test, Trunk Elevation Test, Rotary Stability Test, Hurdle Step, In-line Lunge, Active Straight-Leg Raise, & Trunk Stability Push-up

• Simpllified scoring system The screens are scored from - 0 to - 2. The patient or athlete has three attempts to successfully perform the screen. – (- 0) is given if the individual can perform the screen without compensation. – (- 1) is given if the individual can successfully perform the screen with

compensation. – (- 2) is given if the individual is unable to perform the screen.

Putting It All Together Part 1

First Step

Start With Performing a Postural Analysis

Second Step

• Perform the Post (Minimally Invasive) Thoraco/Lumbar Spine Surgery – Physical Ability Evaluation

Post Surgical Rehab Protocols

• Post (Minimally Invasive) Surgical Thoraco-Lumbar Spinal Patient

• Based upon the results of the patient’s Postural & Physical Ability Exams

Rehab Theory

• Suggests that Rehab Exercise protocols should generally progress in stages– Simple >>>>complex– Isometric>>>isotonic/kinetic exercises– More complex maneuvers (ie. proprioceptive neuromuscular

facilitation (PNF) techniques. – Incorporate FMS/SFMA (Selective Functional Movement

Assessment) – Greg Rose, DC, co-founder of TPI, Engineer• Develop treatment protocols based on the screens

Thoraco-Lumbar Spinal Rehab Stage 1

Remember…

• Each exercise that is added to either the Stage I, II, or III Rehab protocols must be based upon the findings of both the postural and the physical ability exams

• The typical Rehab program is generally scheduled on a 3X per week basis.

The Duration of the Patient’s Rehab Program is dependent upon:

• The severity and complexity of the patient’s initial presenting complaints

• The results of the patient’s Physical (Functional) Ability & Postural Exams

• The complexity and invasiveness of the patient’s surgical procedure

Rehab for L/S ProceduresFrom least to most minimally invasiveLumbar Spine Rehab Duration Guidelines• (4 – 7 Weeks) Facet thermal ablation• (4 – 7 Weeks) RegenaDISC℠

• (6 – 10 Weeks) Lateral Endoscopic Discectomy• (6 – 10 Weeks) Laminotomy• (6 – 10 Weeks) Foraminotomy• (6 – 10 Weeks) Endoscopic discectomy (performed in conjunction with laminotomy)• (8 – 12 Weeks) Decompression with Interlaminar Stabilization™ Device – (COFLEX)• (8 – 12 Weeks) Lateral lumbar interbody fusion (LLIF)• (8 – 12 Weeks) Transforaminal lumbar interbody fusion (TLIF) – more commonly performed than LLIF

Rehab for C/S Procedures From most to least minimally invasive

Cervical Spine Rehab Duration Guidelines• (4 – 7 Weeks) Facet thermal ablation (DTA)• (6 – 10 Weeks) Laminotomy• (6 – 10 Weeks) Foraminotomy• (6 – 10 Weeks) Endoscopic discectomy• (7 – 12 Weeks) Anterior cervical discectomy fusion (ACDF)• (8 – 14 Weeks) Cervical disc replacement

Important for the DC

Post-op contraindications:1. No HVLA manipulation/adjustments to the region for 3 months following

surgery-gentle mobilization 6 weeks post op, grade 1 and 2 (not in to PPS) -some passive pain modalities are acceptable earier.

2. No spinal “decompression”/mechanical traction for 3 months post-op3. No weight resisted exercise for 6 weeks following surgery.

-Light weight and high repetition exercise can be started after 6 weeks, as long as these are pain free and supervised

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Common Chiropractic Techniques • LLLT (laser)• Cryo/HMP• EMS/TENS/Microcurrent • Acupuncture• Ultrasound• Biofeedback• ART/MRT/Graston/Nimmo etc.• Instrument CMT (Activator/Impulse etc.)• FnD, Cox, DRX/DTS/Saunders traction (static vs. intermittent)• Mobilization/CMT• PNF/PIR/Flexibility stretching techniques• Elastic Therapeutic Taping (i.e. Kinesiotape)• Static and Dynamic spine stabilization – strengthening & endurance

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LSI Post-op RecommendationsRecommendations:

1. Aquatics and pool walking can be started after 3 weeks provided the wound is completely healed2. Stenotic patients are encouraged to do frequent short walks and avoid long distance walking.3. MANUAL (NOT MECHANICAL) traction can be started after 6 weeks using grade 1 and 2 for pain control.4. Manual therapy- soft tissue release, massage and joint mobilization grade 1 and 2 are acceptable treatments.5. Modalities such as ultra-sound, e-stim and laser for pain management are acceptable.6. Exercises, posture and gait as determined by the patient’s pathology are appropriate. We encourage walking, abdominal bracing

and neural mobilization for bulging or herniated discs. Flexion exercises, stabilization and neural mobilization for stenosis and flexion rotation exercises for facetogenic problems. Many of our patients have a mixed pathology requiring a balance of these treatments. Avoid stretching exercises for 6 weeks or discontinue them at anytime it increases patients symptoms, especially Radicular pain.

7. All patients should have body mechanics and correction of activities of daily living addressed.—THE BIG IDEA!8. Treatment should relieve pain and symptoms and exercises should improve the patient’s condition and be immediately

discontinued if they cause pain.

SURROUND THE DRAGON

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Resuming Vitamin/Supplement & OTCs

• 48-72 hours after surgery patients can take anything over the counter for any symptoms they need to (constipation, cold/flu, allergies, ibuprofen, etc.) as long as it doesn’t counteract/interact with anything they are already taking. (i.e. patients are told not to take pain medications with Tylenol as most already have Tylenol in them).

• No NSAIDs for MIS patients (3 months for MIS pts.).• Use precautions with supplements with anti-inflammatory/blood thinning/fibrinolytic

properties for first 3 weeks post-op - MIS LONGER– Avoid Omega-3, Vit. E, Selenium, Garlic, ginger, cat’s claw, CoQ10, gingko, green tea, niacin,

proteolytic enzymes (bromelain/papain), turmeric, white willow, feverfew, danshen are common examples

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Return to Golf Guidelines• LFD

1. At 3-4 weeks, can begin chipping/putting2. If chipping/putting are px. free – may move to driving range

• Start w/ short irons, move to mid-irons then to long irons and clubs as long as no subjective pain3. When driving range is px. Free, then try a round of nine hole. If nine px. free, then ready for 18

holes• If a Percutaneous Laser Discectomy or Endoscopic Discectomy follow the above guidelines beginning at 6

weeks• If a Destructive Thermal Ablation (DTA) – you can begin above at 3 weeks• If a stabilization or fusion procedure – you can begin at 12 weeks provided f/u x-rays with surgeon eval.

show proper fusion taken place* Addl: Running: can begin to tolerance at 6 weeks for LFD procedures

Remind patient to “listen to the body”, if it hurts then stop. Ice therapy the first few times after golf play and/or practice

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Major References1 Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116 2Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98. 3Medical Bulletin, April 21, 1981. Globe International Group. Box 21, Rouses Point, NY, 12979. 4Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81. doi: 10.1016/j.berh.2010.10.002. 5Guides to the Evaluation of Permanent Impairment American Medical Association, 5th Edition 2000, 6th Edition 2007. 6Muscle Function Testing. V. Janda. Butterworths, London, England, 1983 7Rehabilitation of the Spine. C. Liebenson. Lippincott, Williams & Wilkins, 2nd Edition 2007. 8 Movement. Gray Cook. On Target Publications, 2010. 9 Low Back Syndromes, Integrated Clinical Management. C. Morris. McGraw-Hill, 2007. 10 Low Back Disorders, Evidence Based Prevention and Rehabilitation. S. McGill. Human Kinetics Publishers, 2nd Edition 2007. 11Numerous articles from the Journal of the North American Rehab Specialist published by the ACA Rehab Council.

Questions?ANTHONY A. GROSS, DC, CCSP, FIAMA Consult PhysicianLaser Spine InstitutePh: 480-391-8500 x8575

Jeffrey Langmaid, DC Consult PhysicianLaser Spine InstitutePh: 813-289-9613 x7054

JERROLD J. SIMON, DC, DACBM, DACRB, DABDA, DIBEPh: 740-653-2973www.jsimondc.com

GEORGE K. PETRUSKA, DC, DACRBPh: [email protected]

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