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Lumbar Fusion by Thomas Andrews (Physiotherapist)

lumbar fusion diagram
lumbar fusion diagram

What is it?

In people with severe back pain or nerve referral down the leg, a lumbar fusion may be recommended. A lumbar fusion is a surgery that permanently connects two or more vertebrae of your spine together.  This is done with metal plates, screws and rods in the vertebrae. This technique holds the two vertebrae still and stops any movement at this area of the spine. Often during this surgery, the surgeon may release or trim areas that are compressing nerve structures to relieve pain.

When is it indicated?

Lumbar fusions are usually indicated for those people who have persistent high levels of pain despite trialling conservative treatment. For example; Physiotherapy, medication and injection therapies. Usually this occurs in people who have the following conditions:

    • disc herniations (disc bulge)
    • spinal scoliosis (irregular curves in the spine)
    • sciatica or nerve irritation
    • severe arthritis of the back (stenosis)
log roll
log roll

What to expect in the hospital:

After the surgery, you will be in hospital for at least the next 4 days to allow time to recover. During this period, physiotherapists and nursing staff in the hospital will assist you getting out of bed, walking and completing daily tasks.  Your surgeon will likely recommend that you do not to bend or twist following surgery for a number of weeks.

Getting out of bed after lumbar fusion or with severe back pain can be difficult. It is recommended that you use the log roll manoeuvre as shown in the diagram.  This reduces movement at the spine, which may help reduce pain and protect the area.

What to expect once your home:

After discharge from hospital, the first six weeks post surgery includes basic exercise, walking, and other light activities. It is not recommended that you avoid heavy house-hold duties during this time. After surgical review at 6 weeks, your surgeon may recommend Physiotherapy. Due to the screws and plates and the pain in your back, you are likely be stiffer in that region, making simple tasks such as putting on shoes and socks difficult. Physiotherapy following a lumbar fusion is recommended to assist in activating muscles in the back, core and legs and to support the injury area.  Treatment may also include nerve stretching, Clinical Pilates and manual therapies.

How can we help you:

Physiotherapists can use hands-on techniques to help improve movement of your back, reduce pain and facilitate muscle activation. Physios can also develop a tailored exercise program dedicated to your needs, to assist you in getting back to activities that you want to do.

Below are some exercises that we often give patients immediately after lumbar fusion to help get you started.

Transversus abdominus muscle activation.

The transversus abdominus is a deep core muscle that helps support the both the abdomen and the spine. After lumbar fusion surgery, this muscle has some difficulty working and supporting the spine. This exercise is aiming to jump start this muscle again to get it working. This may help to decrease pain after lumbar fusion and help to ensure the spine is supported.

To complete this exercise, you slowly draw your lower abdomen in, hold it for 3-5 seconds and then release.

Hip abduction

This exercise aims to build up the strength in the hip muscles to create a stable and strong foundation for the back.

To complete this, bring one leg to the side whilst standing upright. Hold this position for up to 3 seconds and then bring it back in.

Chair squats

This exercise is aimed at improving leg and hip strength. It also works on coordination of the lower back muscles.

To complete this, stand whilst holding onto a back of a sturdy chair or kitchen bench, keeping your back straight, bend your knees making sure they don’t go past your toes. Make sure you don’t squat down too low and return back. You can progress this exercise by removing the chair and completing a squat to the same height.

Book an appointment today for your assessment!

Back Pain Myths

Around 1 in 6 Australians suffer with back pain each year (Australian Institute of Health & Welfare, 2017). Socialising, working or doing the things that you love may become demanding  due to back pain which can in turn have a big impact on life; retiring early, loss of independence and a feeling of confinement. This is avoidable!! And changing thinking around misconceptions of back pain can be a starting point.

Challenging myths

  • Persistent back pain can get better. Scans are not routinely requested because often imaging results do not change management strategies
  • Back pain is rarely caused by something being out of place, spines do not “crumble” and discs do not “slip”
  • Bed rest is not helpful; it can cause stiffness of joints, muscle shortening and general deconditioning alongside building a fear of pain associated with moving and exercising
  • Surgery is rarely needed and is not a quick fix. For example, there is more and more research surfacing to show that surgical treatment does not provide faster relief from back pain symptoms in patients with lumbar disc herniation at a long-term follow up when compared with patients managed in physiotherapy (Gugliotta et al, 2016; Jacobs et al, 2011; Lequin et al, 2012).
  • Stress, low mood, worry and poor sleep influence back pain. Learning about what pain means and where it comes from can help with management – ask your physiotherapist to explain pain science to you
  • Belts, corsets, orthotics and many other gadgets should not be routinely used
  • Traction is not routinely offered as an effective treatment. Manual therapy may be used as a part of a treatment plan including exercise and education
  • Continuing to go to work with modified duties and a return to full duties plan is helpful
  • A “quick fix” is usually not possible and a long-term management plan is more effective
  • Spines are strong structures and can manage bending, lifting and daily stresses
  • A back reactivation programme may include strengthening, stretching, conditioning of the entire body and an education component. This is important to build a strong and stable body however it can take a long time to gain strength and condition, so it should be persevered with for at least 6 weeks. It should also be progressive and you may feel muscle soreness after exercising

How can I help my back pain?

  • Staying active – find something that you enjoy doing on a regular basis. Discuss with your physiotherapist how to integrate back into your hobbies
  • Aiming to avoid relying on medication, scans and surgery unless all other options have been tried – exercise programmes take time to work so give it time to take effect
  • Sleeping, relaxing and looking after yourself – try mind maps including things that empower you and lifestyle factors which you feel may contribute to back pain. Devise strategies to increase activities which empower you and decrease activities which hinder you . You can discuss this with your physiotherapist
  • Create short-term goals with a timeframe in mind to increase activity step-by-step which contribute towards a bigger end goal
  • Developing a better understanding about what pain means – pain is often associated with damage however this is not necessarily the case. Pain is produced by the brain so it can persist after tissues have healed. Your physiotherapist can explain this to you in further detail
  • Developing thinking strategies – the pain and anxiety areas of the brain sit closely and signals can become mixed meaning anxiety may cause more pain which may cause more anxiety and so a vicious cycle is entered . Psychological therapy can be effective in the treatment of back pain as a part of a treatment plan
  • Varying posture and moving in a confident and relaxed way – the spine is designed to move so bracing due to pain is not helpful.
  • Do not fear bending and lifting – the spine is a strong and stable structure, lift in a way that makes you feel comfortable. Repetitive heavy lifting should be 50:50; half squatting and half bending. Avoiding these manoeuvres may even weaken the back. If the load is more than you can manage, seek help from somebody else
  • You should seek medical attention if you have acute back pain with progressive leg weakness or abdominal pain
  • Seek advice from a physiotherapist for information specifically tailored to your back pain, to help you to integrate back into your daily activities as quickly as possible and to learn back reactivation exercises to reduce frequency of reoccurrence as early as possible

Book an appointment today for your assessment!

Blog by Lauren Palmer (Physiotherapist)

Sacroilliac Joint Dysfunction – Blog by Claire De Vos (Physiotherapist)

What is Sacroiliac Joint Dysfunction?

The sacroiliac joints (SIJ) are the joints that connect your lower spine to your pelvis. The sacrum (tail bone) connects to the ilia (pelvic bones).

In most people, the SIJ is a stiff joint that provides a stable link between the lumbar spine and pelvis, allowing only a few degrees of movement.

Causes:

In some people, due to either trauma, generalised joint hypermobility or pregnancy the SIJ has excess mobility, resulting in sheering forces through the joint that may cause pain and dysfunction. Pain in the SIJ due to hypomobility (too little movement) or hypermobility (too much movement) is referred to collectively as sacroiliac joint dysfunction.

SIJ hypomobility may be the result of conditions such as ankolyising spondylitis and is relatively uncommon, whereas joint hypermobility is far more common and will be discussed further.

The sacroiliac joint relies on both force closure and form closure to provide joint stability.

Form closure comes from the anatomical shape of the sacrum and iliac bones, as well as ligamentous support whilst force closure comes from the muscles that attach, and act around the SIJ to provide stability during movement.

Research shows that the most important muscles for SIJ stability are the deep gluteal muscles and the deep “core” muscles, specifically transverse abdominus.

When these muscles become weak, due to trauma or disuse the sacroiliac joints a vulnerable to excessive movement which may result in inflammation and irritation of the joint and surrounding tissues.

The sacroiliac joint may also be susceptible to excessive movement due to joint hypermobility, as a result of either generalised joint hypermobility or pregnancy.

During pregnancy hormones, a released that increase ligamentous laxity. This is to allow the pelvis to move during labour to allow the baby passage through the birth canal.

Unfortunately, this increase in ligamentous laxity, whilst essential for natural delivery of a baby can result in excessive movement of the sacroiliac joint and subsequently, pregnancy related pelvic girdle pain.

Symptoms:

SIJ pain may, at times, be difficult to distinguish from other back and hip injuries as it can behave in a similar way and cause radiation into the lower back, groin, buttock and even down the leg.

Common symptoms of SIJ dysfunction include:

  • Pain in the lower back that may radiate into the hip/groin/gluteal region
  • Pain that is worse with standing, walking.
  • Pain may be aggravated by activities that cause shearing stresses through the pelvis such as rolling over in bed and getting in and out of the car
  • Pain when lying on your side at night
  • Pain with sitting cross legged
  • Pain may be associate with hormonal changes in women, or during sexual intercourse.

Diagnosis:

Accurate diagnosis of SIJ dysfunction may be difficult as SIJ pain can often mimic mechanic low back pain or hip pain.

Clinical diagnosis by your physiotherapist is recommended as your physiotherapist will conduct various tests to deduce the primary cause of your pain. In many cases, there may be multiple contributing factors to low back and SIJ pain and the may exist concurrently. Your physiotherapist will conduct a thorough patient interview and physical examination to determine the cause of your pain.

Diagnostic imaging is not indicated in most instances as it has a poor correlation with symptoms. However, your physiotherapist may recommend imaging to screen for other conditions if necessary or if you are not improving with treatment.

Treatment:

Your physiotherapist will work with you to develop a treatment plan that is specific to you, and your goals. Physiotherapy management of SIJ dysfunction will typically involve several stages including:

  1. Decrease pain and inflammation
  2. Restore strength and neuromuscular control
  3. Return to daily activities/sport
  4. Maintenance to prevent reoccurrence of injury

Decrease pain and inflammation:

In the early stages of rehabilitation your physiotherapist will recommend that you offload your sacroiliac joint to decrease pain. Strategies may include; rest from or modification of aggravating activities, soft tissue release or dry needling, ice or heat therapy, exercises for your core and gluteal muscles, anti-inflammatory medication and in some cases a brace may be recommended.

Restoring strength and neuromuscular control:

Once inflammation of the joint and pain has reduced your physiotherapist will focus on restoring strength and neuromuscular control of the muscles surrounding the SIJ.

Of importance, the deep abdominal (transverse abdominus) and gluteal muscles have been shown to provide support for the sacroiliac joint.

Your physiotherapist will prescribe a home exercise, or in room exercise program that is aimed at improving recruitment patterns (neuromuscular activation) and strength of these muscles. Your physiotherapist may recommend a period of supervised clinical Pilates to rehabilitate your SIJ dysfunction, particularly in the case of pre and post-natal women.

Return to daily activities/sport:

As your pain decreases and your strength improves your physiotherapist will focus on a gradual return to activities.

Your activity levels pre-injury and goals for future activities will be considered when developing your treatment plan and will be individualised to suit you.

During this stage, you will continue to improve your strength, joint proprioception and neuromuscular control whilst focusing on correct joint alignment.

Maintenance to prevent reoccurrence of injury:

Once you are pain free and have returned to your goal activities it is important to continue some element of your rehabilitation program to prevent re-injury.

Your physiotherapist will work with you to develop a maintenance program which may include a focus on your lower limb and lumbopelvic strength and control.

 

Book an appointment today for your assessment!

Blog By Claire De Vos (Physiotherapist)

Low Back Pain

Pain in the lower back is extremely common and is responsible for a large number of visits to health professionals. It is estimated that 70-90% of Australians will suffer from lower back pain at some point in their lives. As common as low back pain is however, it is avoidable in most cases and not normal.

Causes :

Back pain is predominantly musculoskeletal in cause and can relate to the bones, joints, connective tissue, muscles and nerves of the back. Low back pain can be referred to as acute onset or gradual onset. It is normally a result of a sudden/traumatic injury or a sustained over-stress injury.

A traumatic injury can involve an incident where a person is bending forwards awkwardly to pick up a heavy load and experience a sudden onset of pain. Pain that is of gradual onset can be related to sitting in an improper posture in a new chair over a period of months. In these cases, postural fatigue creates micro trauma which accumulates and overloads certain structures in the back, resulting in pain.

Common causes of low back pain are listed below:

  • Disc bugle/ herniation
  • Back muscle strain
  • Ligament sprain
  • Fracture
  • Trauma
  • Non specific low back pain
  • Systemic conditions

Assessment :

Physiotherapists specialise in the assessment and treatment of low back pain as well as many other injuries. During an initial consult, your physiotherapist will ask you a wide range of questions which all assist in the identification and classification of your low back pain. You may then be asked to perform a range of movements of your lower back to identify if any of these movements or postures aggravate your pain. Your physiotherapist may then feel along your spine, muscles and ligaments in your back to further narrow down your source of pain.

Using all this gathered information, your physiotherapist will be able to diagnose the cause of your low back pain, and furthermore devise a treatment plan for you.

Treatment :

Treatment for low back pain needs to be individualised and can usually be divided up into 4 phases.

  1. Pain relief and protection

Managing pain is very important in the initial stages of treatment. Your physiotherapist you assist in reducing pain and inflammation using a range of techniques tailored to you. Examples include: soft tissue massage, taping of your lower back and non-steroidal anti-inflammatory medications. Exercises to relieve pain may also be prescribed.

  1. Restoring movement and strength

Once your pain is reduced, it is important to regain normal movement of your back and strength. This is achieved by completing specific exercises prescribed by your physiotherapist.

  1. Restoring full function

If your low back pain has been restricting you from participating in activities, hobbies or work, then the next stage of rehabilitation involves restoring your back’s function to allow you to return to these activities. This aspect of rehabilitation is very goal specific.

  1. Preventing recurrence

If not rehabilitated properly, the likelihood of your low back pain recurring is increased. To reduce the chance of recurrence it is very important that you move thoroughly through all phases of rehabilitation and also complete specific exercises to prevent recurrence. Clinical pilates has also been shown to reduce recurrence.

Low back pain is very common, however it is not normal. If you are experiencing low back pain then please feel free to come in for a comprehensive assessment with one of our physiotherapists.

Book an appointment today for your assessment!

Blog by Alice Smith (Physiotherapist)

What difference is there between clinical pilates and pilates?

What is Clinical Pilates?

It is based on the original Pilates method which was developed by Joseph Pilates in the early 20th century. It is a form of exercise that focuses on correct posture, core stability, balance, control, strength, flexibility, and breathing. The advantage  is that you work on muscle control rather than strength, with the exercises working muscle groups in patterns that are functional. There is strong evidence in the literature to support the use of therapeutic exercises, including pilates for many different conditions, particularly in low back pain.

Difference between normal and Clinical Pilates:

As Physiotherapists we often get asked “What is the difference between Clinical and regular Pilates?”. While both types may use either equipment or mat work, there are several importance differences between the styles.

  • Pilates

Gym instructors run the the classes as fitness classes. The exercises are not tailored to meet the specific needs of the client and there are often many people in a class. This means that it is difficult for the instructor to ensure proper technique or to give options for specific conditions, making it inappropriate for people with injuries or special requirements. Doing the wrong exercise can be detrimental and could make your low back condition worse.

  • Clinical Pilates

Clinical Pilates on the other hand, is run by qualified physiotherapists or exercise physiologists who have underwent training of the human body and who specialise in injury management and prevention. Prior to participating in a class you will be thoroughly assessed by an experienced trained physiotherapist. This will ensure that all your exercises are tailored to your specific needs. This is particularly important for anyone with a history of injuries, as certain exercises may aggravate particular conditions if not completed correctly. During a clinical pilates class your Physiotherapist will constantly monitor your technique and, where necessary, progress your exercises.

Who can do clinical Pilates?

It is appropriate for all age groups, from kids, to pregnant women and the elderly.

As the exercises are tailored to the individual your physiotherapist can make your program as challenging or gentle as it needs to be to achieve the best outcomes for you.

You don’t need to have an injury to attend, many clients come to keep fit and healthy, enjoying the personalized attention that a small class size allows. It gives them the peace of mind to know that they are performing the exercises correctly under supervision.

People who would benefit from clinical Pilates:

  • Back, neck or shoulder pain
  • Pelvic or hip pain
  • Athletes looking to improve their technique e.g. golfers, gymnasts, dancers, runners
  • Post orthopaedic surgery
  • Pre and post-natal
  • Pelvic floor retraining
  • Postural and flexibility issues
  • General conditioning, toning and fitness

Total Physiocare offers both individual and small group classes. All classes run by qualified trained Physiotherapists. Enquire today about getting started!

Total Physiocare also has a 6 week better back program which is designed to individually personalise your program. Find out more about this program here.

Blog post by Claire De Vos

 

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Lumbar Spinal Stenosis

What is Lumbar Spine Stenosis?

Lumbar Spinal stenosis is a common medical condition, affecting the lower (lumbar) region of the back. It is a condition that increases in prevalence in an aging population and is a frequent reason for spinal surgery for adults over 65.

Spinal stenosis is characterised as an abnormal narrowing of the spinal canal – which is where the spinal cord runs. This leads to the compression of neural (nerve) and vascular (blood) structures within the spinal canal. This compression results in a painful presentation that can greatly impact and limit a person’s participation in day to day activities.

It is important to highlight at this point, that although spinal stenosis can be a debilitating condition, it is not life threatening.

back

Symptoms:

Patients with spinal stenosis often complain of pain and weakness in the lower back, buttocks, thighs and lower legs. Patients often describe their symptoms such as an ache in the back, cramping or heaviness in their lower extremities. Such discomfort is commonly aggravated by prolonged standing and with prolonged walking.

back 2

How does it occur?

Acquired lumbar stenosis occurs as a result of age associated degenerative and/or arthritic changes that affects the lumbar spine. This affects the vertebral bones, the spinal joints and the discs between each spinal segment. This phenomenon can be explained in four steps:

  1. The earliest changes occur in the discs in-between each spinal segment. These discs may dry out and begin to flatten which can lead to a bulging disc and/or collapse of the disc segment.
  2. The loss of structural integrity of the disc causes additional stress on the spinal joints and ligaments (which connect the spinal vertebrae together). One of the important ligaments affected is the ligamentum flavum, which has a role in preserving upright posture and returning the spinal column to its original position after flexion (bending) movements.
  3. As a result, the extra stress may promote bone growth (osteophyte formation) and thickening of the ligamentum flavum.
  4. The area within the spinal canal and as the spinal nerves exist the vertebral column becomes narrowed due to the combination of the disc bulging, bone formation and ligament thickening. These factors results in less space for the spinal nerves and blood vessels.

stenosis

The spinal canal and space also narrows further when placed in extension, hence limiting standing, walking and similar activities.

Physiotherapy management and treatment:

Physiotherapy management to treat lumbar spine stenosis aims to maximise the vertebral canal space and minimise canal narrowing. This can be achieved by reversing or reducing tissue inflammation and oedema in the joint space, strengthening the abdominal muscles, avoiding aggravating movements and activities and commencing a flexion-biased exercise program. Physiotherapy intervention aims to reduce patient symptoms and improve physical activity and function.

Often in moderate to severe cases, surgery may be required. In this case, a procedure called a “decompressive laminectomy” may be utilised to reduce the pressure and narrowing on the nerve roots. Here at Total Physiocare, we have an excellent affiliation with leading spinal and orthopaedic surgeons. Your physiotherapist can assess the severity of your condition, determine the best method of treatment unique to yourself, organise pre and post operative care as required, and prescribe expert rehabilitation exercises.

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Post by Christian Bonello. Copyright 2015.