Spine Care & Rehabilitation

Orthopedic Spine Care & Rehabilitation Program

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St. Mark's Comprehensive Spine Center. 2014 Copying or distributing without written consent is prohibited.

Table of Contents

Table of Contents .................................................................................................................................................................... 2

Lower Back Pain ...................................................................................................................................................................... 3

Lower Back Pain Symptoms and Causes ................................................................................................................................. 3

Back Surgery ............................................................................................................................................................................ 4

Lumbar Spine Functional Anatomy and Physiology ................................................................................................................ 4

Lumbar Spine Disorders ........................................................................................................................................................ 10

Postoperative Nursing Assessment, Interventions, and Monitoring .................................................................................... 12

Case Study ............................................................................................................................................................................. 17

Spine Rehabilitation Patient Evaluation................................................................................................................................ 20

SF - 36® Health Survey (Physical Functioning Score (PFS): TO BE COMPLETED BY THE PATIENT ......................................... 25

Rehabilitation and Exercise Following Spine Surgery ........................................................................................................... 28

One-on-One Training after Spine Surgery ............................................................................................................................. 28

Education about Exercise following Spine Surgery ............................................................................................................... 28

Lumbar Stabilization, Therapeutic Exercise Foundation....................................................................................................... 29

Exercise Progression ............................................................................................................................................................. 30

‘Neutral Spine’ and ‘Neutral Zone’ ....................................................................................................................................... 30

Integrating Exercise Therapy with Stabilization Mechanisms .............................................................................................. 31

Training for Muscular Stabilization ....................................................................................................................................... 31

Level One Lumbar Stabilization Exercises ............................................................................................................................. 32

Level Two Lumbar Stabilization Exercises ............................................................................................................................. 33

Level Three Lumbar Stabilization Exercises .......................................................................................................................... 34

Level Four Lumbar Stabilization Exercises ............................................................................................................................ 35

Walking After Back Surgery................................................................................................................................................... 36

PT Spine Quick Reference Guide (HEP) ................................................................................................................................. 37

About The Instructor ............................................................................................................................................................. 38

Course Evaluation ................................................................................................................................................................. 39

Glossary ................................................................................................................................................................................. 40

References ............................................................................................................................................................................ 46


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Lower Back Pain Over 80% of the population will suffer from some form of lower back pain at some point in their lives. Most cases of lower back pain can be linked to a general cause - such as muscle strain, injury or overuse – or can be attributed to a specific diagnosed condition of the spine. The most common spine related conditions that cause lower back pain are:

1. Herniated Disc 2. Degenerative Disc Disease 3. Spondylolisthesis 4. Spinal Stenosis 5. Osteoarthritis

While less common than the conditions listed above, a number of other conditions can cause low back pain as well, such as sacroiliac joint dysfunction, spinal tumors, fibromyalgia, and piriformis syndrome.

Lower Back Pain Symptoms and Causes

Typically, younger individuals (30 to 60 year olds) are more likely to experience back pain from a lower back muscle strain or from within the disc space itself (e.g. lumbar disc herniation or degenerative disc disease).

Symptoms: Severe or aching pain in the lower back after activity, sudden movement or lifting a heavy object.

These lower back pain symptoms include any combination of the following:

1. Difficulty moving that can be severe enough to prevent walking or standing

2. Pain that does not radiate down leg or pain that also moves around to the groin, buttock or upper thigh, but rarely ravels below the knee

3. Pain that tends to be achy and dull

4. Muscle spasms, which can be severe

5. Local soreness upon touch

Possible causes: Back Muscle Strain

A back muscle strain or ligament strain is one of the most common causes of acute lower back pain. Lifting a heavy object, twisting, or a sudden movement can cause muscles or ligaments stretch or develop microscopic tears. With a lower back strain, the severity of the pain ranges from mild discomfort to severe, disabling pain, depending on the extent of strain and the lower back muscle spasms that result from the injury. Back strains often heal on their own with the help of some combination or rest, ice and/or heat application, anti-inflammatory medications, and/or gradual and gentle stretching and lower back exercises.


http://www.spine-health.com/conditions/lower-back-pain/pulled-back-muscle-and-lower-back-strain

http://www.spine-health.com/conditions/herniated-disc/whats-a-herniated-disc-pinched-nerve-bulging-disc

http://www.spine-health.com/conditions/degenerative-disc-disease/what-degenerative-disc-disease

http://www.spine-health.com/conditions/spondylolisthesis/degenerative-spondylolisthesis

http://www.spine-health.com/conditions/spinal-stenosis/what-spinal-stenosis

http://www.spine-health.com/conditions/arthritis/osteoarthritis-spine

http://www.spine-health.com/conditions/sacroiliac-joint-dysfunction/sacroiliac-joint-dysfunction-si-joint-pain

http://www.spine-health.com/conditions/spinal-tumor/could-my-back-pain-be-spine-cancer

http://www.spine-health.com/conditions/fibromyalgia/fibromyalgia-defining-characteristics-fibromyalgia

http://www.spine-health.com/conditions/sciatica/what-piriformis-syndrome

Back Surgery

Is surgery for back pain necessary? The answer is: sometimes. It is reasonable to consider spine surgery if physical therapy and pain management have not diminished symptoms after these non-surgical treatments and or if your pain does not respond to narcotic medications, or if you are unable to complete basic daily activities. But there is a wide array of surgery options. Some are minimally invasive procedures (e.g. microdiscectomy for a herniated disc) allow for a quick recovery, while other types of surgery (e.g. a poster or lateral fusion for degenerative disc disease) are more extensive and have a much longer recovery time. Understanding your surgery options will help you better decide on a course of action.

Lumbar Spine Functional Anatomy and Physiology

I. Lumbar Vertebrae The lumbar spine is formed by five vertebrae. The vertebrae are commonly referred to as L1 through L5. L1 is the most superior vertebra in the lumbar spine, and it abuts the thoracic spine, whereas L5 is the most inferior vertebra and abuts the sacral spine. The anterior or ventral element of each vertebra is called the vertebral body. The vertebral bodies of the middle and lower lumbar spine are more substantial in size to allow them to bear greater loading forces. Posteriorly, or dorsally, each vertebra has a bony arch that encircles the spinal canal. It is composed of two transverse processes, two sets of facet joints, two pedicles, two laminae, and one spinous process. The bony arch, also referred to as the posterior elements, is quite bulky. It provides the necessary support for upright posture (Figure 1).

Figure 1. Lumbar vertebra


http://www.spine-health.com/treatment/back-surgery/microdiscectomy-microdecompression-spine-surgery

http://www.spine-health.com/conditions/herniated-disc/whats-a-herniated-disc-pinched-nerve-bulging-disc

http://www.spine-health.com/conditions/degenerative-disc-disease/what-degenerative-disc-disease

The non compromised spinal canal has ample room for the cauda equina and for cerebrospinal fluid (CSF).

The cauda equina (Latin for "horse's tail") is a bundle of spinal nerves and spinal nerve roots, consisting of the second through fifth lumbar nerve pairs, the first through fifth sacral nerve pairs, and the coccygeal nerve, all of which originate in the conus medullaris of the spinal cord.

Facet joints (bilaterally) are composed of a superior articulating process and an inferior articulating process. The superior articulating process forms a joint with the inferior articulating process of the vertebra above (e.g., superior articulating processes of L3 forms two facet joints with the inferior articulating processes of L2). They have a loose capsule and a synovial lining; thus they are apophyseal joints (Figure 2).

Figure 2. Lumbar spine: Posterior view

The nerve root canal, also called the lateral recess, is adjacent to the pedicles and facet joints in the region of the foramina. It encompasses the nerve root as it exits the spinal cord (Figure 3).

Figure 3. Lumbar spine: Lateral view


http://en.wikipedia.org/wiki/Spinal_nerves

http://en.wikipedia.org/wiki/Lumbar_nerve

http://en.wikipedia.org/wiki/Sacral_nerve

http://en.wikipedia.org/wiki/Coccygeal_nerve

http://en.wikipedia.org/wiki/Conus_medullaris

http://en.wikipedia.org/wiki/Spinal_cord

The neural foramina, also referred to as the intervertebral foramina, is the actual far-lateral exit opening of the nerve root canal (Choi, 2009). The lumbar vertebral, or spinal, canal is supported anteriorly by the posterior edge of the vertebral body as well as the posterior longitudinal ligament. This ligament lies on the posterior vertebral body surface. The lateral elements of the vertebral canal are the pedicles and the facet joints, with corresponding articular capsules. Posteriorly, the vertebral canal is formed by the laminae and ligamenta flava. II. Intervertebral Disc Each intervertebral disc in the lumbar spine provides support and facilitates movement while resisting excessive movement. The disc permits slight anterior flexion, posterior extension, lateral flexion, rotation, and some circumduction (Shankar, Scarlett, & Abraham, 2009). The disc is the largest avascular structure in the body (Singh, Masuda, Thonar, et al., 2009). It is composed of the nucleus pulposus and the annulus fibrosus. In someone less than 35 years old, the nucleus pulposus is soft, rather like crab meat in texture. With aging, the nucleus pulposus dehydrates. Surrounding the nucleus pulposus is the annulus fibrosus, which is tough and fibrous. The fibers of the annulus fibrosus are concentric, like the layers of a radial tire. The concentric arrangement provides great resistance and strength. Each disc is bonded to the vertebral body below and above it by a thin cartilaginous plate, referred to as the endplate (Figures 4, 5).

Figure 4. Intervertebral disc in relation to endplate and vertebral body

Figure 5. Intervertebral disc

The endplate resists herniation of the disc into the vertebral body and gives the disc its shape. (Hicks, Morone, & Weiner, 2009).


III. Ligaments Each disc is reinforced anteriorly by the anterior longitudinal ligament and posteriorly by the posterior longitudinal ligament. The laminae are connected by an elastic yellow ligament called the ligamentum flavum. Each facet joint is connected to a capsular ligament. The transverse processes are connected by intertransverse ligaments. The rotator brevis and rotator longus ligaments connect the transverse processes to the laminae of the superior two vertebrae. The spinous processes are connected by the supraspinous and infraspinous ligaments (Figures 6, 7, 8; Choi, 2009).

Figure 6. Ligaments of the lumbar spine

Figure 7. Ligaments of the lumbar spine: Posterior view


Figure 8. Ligaments of the lumbar spine: Lateral view

IV. Biomechanics The functional unit of the spinal column is the motion segment. A motion segment is composed of two adjacent vertebrae, the disc between them, the facet joints connecting them, and the ligaments attached to the vertebrae (McGill & Karpowicz, 2009). The geometry and health of the functional units help a surgeon determine which patients will benefit from surgery, as well as the most appropriate surgical intervention for a given patient. V. Spinal Cord The spinal cord ends at approximately the L1–L2 level in an adult. The conus medullaris is the end of the spinal cord. The filum terminale is an extension of the pia mater, which descends below the conus medullaris and is anchored to the coccyx. VI. Nerve Roots The cauda equina is a fanning bundle of lumbar and sacral nerve roots exiting off the spinal cord at the conus medullaris. This mass of nerve roots provides communication with the lower extremities and controls bowel, bladder, and sexual function (Figures 9, 10).


Figure 9. Termination of spinal cord at conus medullaris; cauda equina; and termination of dura in coccyx

Figure 10. Dermatomal distribution of lumbar nerve roots


The cauda equina is relatively resistant to neurologic insults, compared with the spinal cord (Shankar, Scarlett, & Abraham, 2009). The exiting nerve root in the lumbar spine is numbered according to the pedicle above it. For instance, the L5 nerve root passes below the L5 pedicle. (See Table 1.)

Lumbar Spine Disorders Herniated Nucleus Pulposus: Description and Etiology Intervertebral disc herniation is also known as herniated nucleus pulposus (HNP). HNP may be asymptomatic despite radiographic evidence of bulging, protrusion, or extruded disc The etiology may be either nonspecific or attributable to a precipitating event. Even when the patient is symptomatic, surgical intervention often is not required. An HNP may be symptomatic due to a combination of direct nerve root compression, the release of inflammatory chemicals (e.g., matrix metalloproteinases, prostaglandin E2, interleukin- 6, nitric oxide), and hypoxia of the nerve root and basal ganglion (Ireland, 2009). Radicular pain can be accompanied by paresthesias or paresis (i.e., weakness) in the anatomic distribution of the affected nerve root. The patient may complain of low back pain. The back or leg pain may be aggravated by coughing, sneezing, or assuming certain positions. Lumbar Stenosis: Description and Etiology The normally triangular-shaped spinal canal becomes flattened, compressing the thecal sac. As it progresses, the cauda equina is compressed. This can be caused by any of the following, or any combination of the following: • facet hypertrophy • thickening and bulging of the ligamenta flava • outward disc bulging • disc degeneration • spondylosis • degenerative spondylolisthesis. The condition is aggravated by positions of extension, which produce more central-canal and lateral-recess narrowing.


Bracing In this population, braces may be used to decrease lumbar lordosis, which may decrease pain. However, prolonged use may cause muscle atrophy, which can increase back pain. Spondylosis: Description and Etiology Spondylosis is the result of disc degeneration, which leads to bulging of the annulus fibrosus. The degenerated, bulging annulus fibrosus creates an elevation of the periosteum. Bony reactions occur, resulting in osteophyte formation. The osteophytes commonly occur in the lordotic spinal canal of the lumbar and cervical spine (Middleton & Fish, 2009). In addition, there may be hypertrophy and buckling of the ligamentum flavum, leading to further lumbar spine canal narrowing. With disc collapse, the neural foramina will decrease in height, which may result in nerve root compression. Alterations in axial loads may lead to posterior facet osteophyte formation, which can also result in nerve root compression (Singh & Phillips, 2005). Motion segment degeneration can lead to stiffened levels, exhibiting disc degeneration, ligament calcification, and osteophyte formation. Conversely, the motion segment can be hypermobile, as in degenerative spondylolisthesis (Watters, et al., 2009). The degenerative cascade, a part of the aging process, is caused by many factors and affects the discs, facet joints, surrounding soft tissue, ligaments, vertebrae, and articular processes. Middleton and Fish (2009) noted that the spondylotic process is lessened by fusion or immobilization. Spondylolisthesis and Spondylolysis: Description and Etiology Spondylolisthesis comes from the Greek words spondylo, meaning vertebrae, and listhesis, meaning slipping or sliding. It most often occurs at L5–S1, followed by L4–L5. The most frequent cause of spondylolisthesis is degenerative changes related to chronic motion between two vertebrae that results in anterior subluxation. Spondylolysis is a defect in the pars interarticularis (bony region between the superior and inferior articulating processes of an individual vertebra). Degenerative Disc Disease: Description and Etiology Degenerative disc disease (DDD) is described as a change in the composition and function of the disc. A disc’s water content and vascularity decreases with age. By the age of 30, there is no longer a direct vascular supply to the discs, and they become desiccated, providing less support and resistance to movement. During the aging process, the nucleus pulposus becomes less elastic, and tears develop in the annulus fibrosis. It is commonly accepted that the disc may become painful if the outer third is exposed to a noxious stimulus. Many patients are asymptomatic despite radiographic degenerative changes. Symptoms include pain, dysfunction, and disability (Chou, Baisden, Carragee, et al., 2009).


Postoperative Nursing Assessment, Interventions, and Monitoring

1. Sensation Assessment Sensory function is rated on a 0 to 2 scale.

Sensory Values:

2 = Normal 1 = Impaired (Numbness or Tingling) 0 = Absent

Test sensation at the following levels:

1. ONE level ABOVE the surgery. 2. ALL levels BELOW the surgery


2. Mobility

a. Patient should mobilize quickly unless ordered differently due to complication (e.g., CSF leak). b. Instruct and help patient to “roll to the side” and bring legs down while simultaneously rising up with the torso from the bed. This minimizes twisting at the waist. c. Instruct and help patient to rise from a chair using the legs, rather than pushing off with the back. d. Bed mobility; teach safe transition in and out of bed. Using a technique referred to as a logroll, this maneuver will enable patients to transfer with minimal stress to the surgical area.

Logrolling; changing body positions while lying down helps blood circulation, prevents pressure sores, relieves muscle tension, and reduces pressure on the surgical site. Right after surgery the nurses will “logroll” the patient while remaining passive by keeping the body stiff and not “helping” the nurses. Then patients will be shown how to “logroll” to change positions while lying down and to change from lying down to sitting up. Logrolling prevents bending, twisting, and straining of the spine which could disrupt the surgical repair. Avoiding bending, twisting, and straining will protect the fusion while it heals. Bone healing starts at about 6 weeks and substantial healing occurs at about 6 months. http://youtu.be/PSCy9NSPj24 Logroll Lying to Sitting Bend both knees to a flexed position. Moving upper body and legs simultaneously, begin to roll towards the side of the bed in which to exit. Slide legs off the bed and begin to rise to a seated position. http://youtu.be/BJtouWmJXro


http://youtu.be/PSCy9NSPj24

http://youtu.be/BJtouWmJXro

Logroll Sitting to Lying Seated at the edge of the bed, keep knees bent and lower yourself onto your side. With knees still in a bent position, begin moving your upper body and legs simultaneously until you are flat on your back. Once in a lying position, allow your knees to extend and relax.

Transfers; Standing up from a Chair, Bed, or Commode. Scoot to the edge of the bed or chair. While sitting at the edge of the bed, position your feet firmly on the floor and ensure that your legs are shoulder width apart. With your hands placed on the bed or armrests of the chair, lean forward as you push with both arms. Do not reach for the walker before standing! Once you are in standing position, reach for the assistive device with one hand and then the other. Push into the walker with both hands until your elbows are straight and you are fully upright.

3. Pain Control a. Do Not Use: Nonsteroidal anti-inflammatory drugs, or "NSAIDs" (Aspirin, Motrin®, Advil®...) they have a delaying effect on bone healing. b. The degree of pain varies considerably with patients, be a wear of the spectrum of pain reporting and pain control. c. Antispasmodics may be prescribed if muscle spasms are present, just check the patient medication list. d. Heat may be applied for spasms and muscular tension. e. Ice may be applied for radicular pain for no more than 20 minutes per hour. f. Gentle massage may be used away from the incision. g. Have patient change positions frequently. No more than 20 minutes in any one position. h. Activity may be conducted as tolerated without BLT. i. If a brace was prescribed, the patient is instructed to wear it whenever out of bed. j. Immediate post spine surgery is NOT the time for new medications. simply insure compliance with the medication list.


4. Constipation prevention a. Ensure adequate water intake. b. Add stimulants to increase gut motility, Senokot-S® c. Diet should include adequate fresh fruits, vegetables, and fiber. d. Stool softener (e.g., docusate) may be used two to three times per day. e. Motility agents (e.g., senna) should be used only as needed. f. Don't add fiber, it bulks up mass g. Encourage fluids, use prune juice. 5. Urination

a. Urinary hesitancy, especially immediately postoperative, is usually transient. b. Assess urinary output, frequency, and volume. c. Ask, “Has your urine output decreased”?

6. Incision Care. a. Check the incision daily for signs / symptoms of infections: • Green / yellow discharge, foul odor, increase in pain at the incision site, increased redness, opening of the incision, flu-like symptoms, temperature above 101.5 degrees. • Some incision drainage is ok, if drainage continues to increase in amount or color, notify the physician with the results of the following evaluation. • Clear fluid, differentiate between cerebral spinal fluid and normal discharge: If the patient has a headache, and it resolves by laying down, do not report this. If the headache worsens in an upright position, without resolving when laying down, suspect a spinal fluid leak, and notify the physician directly.

7. Back Precaution DO’s

DO keep a balanced, aligned position of comfort at all times. When lying on your side, place a pillow between your knees and at your back. DO arrange work areas so they are above your hips and below your shoulders to prevent bending, stooping, or reaching. DO lie down when you rest. Lying down puts less stress on your back than sitting. DO walk as much as possible, increasing distance each week. You can walk outside, but be careful not to fall. DO go up and down steps, unless your surgeon tells you not to. Go slowly, and hold onto the hand rails. DO pace your activities so you don’t get too tired. DO limit visitors. Too many visitors can be very stressful. DO bend your hips and knees when lifting, don’t bend at the waist. Lift with your legs, not with your back. Do use the Back Brace whenever up and or up out of bed.


8. Back Precaution DON’Ts

Don’t lie down on or sleep on the belly / stomach / in a prone position Don’t twist your spine when turning; turn your whole body. Don’t pull on the side rails of the bed or shower; this will strain your back. Don’t reach, stoop, or bend forward at the waist or from side to side. Don’t lift anything heavier than 10 pounds (a gallon of milk); hold objects close to your body. Don’t do excessive physical activity like picking up children, carrying groceries, taking the garbage out, or having sex until your surgeon says it is OK.

9. Provide Patient Education through the North American Spine Society, to summarize:

• Improves understanding of medical condition, diagnosis, disease, or disability. • Improves understanding of methods and means to manage multiple aspects of medical condition. • Improves self advocacy in acting independently of providers and more interdependent. • Increases Compliance – patient education increases patient motivation to comply. • Patient Outcomes – Educated patients respond well to their treatment plan – fewer complications. • See Education Brochures @: http://www.knowyourback.org/Pages/Brochures/Default.aspx

10. Discharge planning

a. Reinforce the following: no lifting, bending, or twisting; no sitting for long periods of time. c. Remind patient to change positions frequently. d. Remind patient not to drive while using narcotic pain medications. e. Ensure the patient is aware of return-to work and activity recommendations.


http://www.knowyourback.org/Pages/Brochures/Default.aspx

Case Study L5–S1 Herniated Disc D. K., a 30-year-old female, had intermittent right-buttock and lower extremity pain, approximately 3 months in duration. Upon presentation to clinic, she had been experiencing acute pain exacerbation for the past 2 weeks. She described the pain as radiating from her right buttock into her posterior lower extremity to her lateral foot. She denied weakness in her right leg, bowel or bladder problems, or any symptomatology in her left leg. Her pain was aggravated by sitting and alleviated by changing positions frequently. She participated in physical therapy for 2 weeks, which exacerbated her symptoms. She also had tried NSAIDs and ice.

A. History and review of systems

1. Social history: Married with two small children. Works as a transcriptionist but had been unable to work for weeks 2. Medical history: Depression, which she noted is under fair control 3. Surgical history: Hysterectomy, tonsillectomy 4. Medications: Wellbutrin, ibuprofen, cyclobenzaprine, hydrocodone/APAP 5. Allergies: No known drug allergies 6. Review of systems: Unremarkable

B. Focused neurologic examination and diagnostics The neurological examination indicated an absent right Achilles reflex and a markedly positive straight leg raise on the right with a positive crossed straight leg test. Her gait was antalgic. Strength and sensation were normal inthe bilateral lower extremities. Her MRI demonstrated a large L5–S1 herniated disc to the right (Figures 32, 33).


Figure 32. L5–S1 herniated nucleus pulposus (HNP): MRI, sagittal view


Figure 33. L5–S1 herniated disc, eccentric to the right: Axial T2-weighted MRI image

C. Further conservative treatment D. K. wished to pursue all nonoperative options. She underwent an Epidural Steroid Injections (ESI) for pain relief the day of the initial clinic visit. Two weeks later, she had experienced a decrease in her pain. However, her ADLs continued to be significantly impaired. She wished to proceed with surgery. D. Operative intervention D. K. underwent an L5–S1 microdiscectomy for a right S1 radiculopathy. She has done well postoperatively, and at 1 year after surgery had no pain and was participating in all of her usual activities.


Spine Rehabilitation Patient Evaluation

PHYSICAL THERAPY EVALUATION

PATIENT NAME:________________________________ DATE ___/___/____ Time In: Time Out:

REASON FOR EVALUATION (DIAGNOSIS/PROBLEM) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ MEDICAL HISTORY □ Hypertension □ Cardiac □ Diabetes □ Respiratory □ Osteoporosis □Fractures □ Cancer □ Infection □ Open wound □ Falls with injury □ Past surgeries:___________________________________________________________ □Other:______________________________________________________________________________________________ PRIOR LEVEL OF FUNCTION ADLS: □ Independent □ Needed assist □Unable □ Equipment used:_____________________________________________ IN-HOMEMOBILITY(gait or wheelchair/scooter) □ Independent □ Needed assist □ Unable □ Equipment used: __________________________________________________ COMMUNITY MOBILITY(gait or wheelchair/scooter) □ Independent □ Needed assist □ Unable □ Equipment used:___________________________________________________ LIVING SITUATION □ Lives alone □ Caregiver: ___________________________ □ Capable □ Willing □ Available □ Limited support HOME SAFETY BARRIERS: □ Clutter □ Throw rugs □ Narrow doorways /hallways □Equipment needs:_______________ STAIRS: □ Entry- ____# Rail? □Yes □No □ Inside home:____# Rail □Yes □No Safe: □Yes □No:____________________ Other: VITAL SIGNS/CURRENT STATUS □ Temperature:____ □ Blood Pressure:___/____ □Pulse :________ □ Respirations:__________□ O2 Saturation:____% □ Edema:__________________________________________________________□ Vision:___________________________ □ Sensation:_____________________________________ □ Communication:_____________ □


Hearing:_______________ □Wounds: BEHAVIOR/MENTAL STATUS □ Alert □ Oriented □ Cooperative □ Confused □ Memory deficits □ Impaired judgment □ Other: POSTURE □ WNL □ Forward head □ Scoliosis □ Kyphosis □ Protracted shoulders □ Hyperlordosis □ Contracture:_____________ □ Other: PAIN Deficit noted □ Intensity 0 1 2 3 4 5 6 7 8 9 10 Location:_______________________________ Origin:______________________ Current :______ Best:_______ Worse:_______ □ Constant □ Intermittent □ Sharp □ Dull How does it affect function? Pain relief measures? MUSCLE STRENGTH/RANGE OF MOTION(ROM) Deficit noted □ AREA RANGE OF MOTION STRENGTH COMMENT RIGHT LEFT RIGHT LEFT CERVICAL SPINE TRUNK SHOULDER FLEX/EXT ABD./ADD INT.ROT/EXT.ROT ELBOW FLEX/EXT WRIST FLEX/EXT FINGERS FLEX/EXT HIP FLEX/EXT ABD./ADD. KNEE FLEX/EXT ANKLE DORS/PLANT. FOOT INV/EVER. COMMENTS: ( Crepitus, Tone, Effusion,Orthotics,braces) FUNCTIONAL ASSESSMENT/ WHEELCHAIR MOBILITY Deficit noted □ □N/A, Wheelchair mobility:□ Propulsion □Power □ Manual :__________________________□ Foot rests:______________ □ Pressure relief:___________□ Brakes:_____________ Other: FUNCTIONAL ASSESSMENT/ BED MOBILITY Deficit noted □ TASK(BED MOBILITY) ASSIST DEVICE/COMMENTS/TEACHING Roll/Turn (MAX A) (MOD)(MIN A)

(SBA) (VC) (I)

Sit/Supine, Supine/sit (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

Scoot/Bridge (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

TASK(TRANSFERS) ASSIST DEVICE/COMMENTS/TEACHING Chair (MAX A) (MOD)(MIN A)


(SBA) (VC) (I)

Toilet (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

Wheelchair □ N/A (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

Bed (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

Tub/Shower (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

Other: (MAX A) (MOD)(MIN A) (SBA) (VC) (I)

FUNCTIONAL GAIT ASSESSMENT Deficit noted □ ASSISTANCE: □ Unable □ Max. assist □ Mod. Assist □ Min. assist □ SBA □ Verbal Cues □Independent Surfaces: □ Level □ Uneven □ Ramp □ In home □ Outdoors Weight Bearing Status: □ FWB □ WBAT □ PWB □ TDWB □ NWB □ Other:_________ Assistive Devices: □ Cane □ Quad cane □ Crutches □ Walker □ Wheeled walker □ Other:_______ Quality/Deviations: □ Spastic □ Ataxic □ Paralytic □ Antalgic □ Staggering □ Retropulsion □ Shuffling Comments: STAIRS/ UNEVEN SURFACES Stairs: #______ □ Assistive device:______________ □ Rail □ Yes □ No □ Safe?:_________________________________ Assist: □ Unable □ Max assist □ Mod. Assist □ Min assist □ SBA □Verbal Cues □ Independent COMMENTS: Walking Speed Deficit noted □ __________ft/sec (Norms: 3.9-4.5 ft /sec) FUNCIONAL BALANCE TESTS Standing Functional Reach Test □N/A Deficit noted □ Age Men (norms) Women (norms) 20-40 yrs 16.7 in. 14.6 in. 41-69 yrs 14.9 in. 13.8 in. 70-87 yrs 13.2 in. 13.2 in. Score: __________ inches *Note: < 7 inches - High fall risk Berg Balance Scale □N/A Deficit noted □ 1) Sitting to standing 2) Standing unsupported 3) Sitting unsupported 4) Standing to sitting 5) transfers 6) Standing with eyes closed 7) standing with feet close

Score 8) Reaching forward with outstretched arm 9) Retrieving object from floor 10) Turning to look behind 11) turning 360 degrees 12) Place alternate foot on stool 13) Standing with one foot in front 14) Standing on one foot

Score 0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4


0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

Total Score( Maximum = 56) □ 0-20= high fall risk □ 21-40 = medium fall risk □ 41-56 = low fall risk

Total:

(TUG)- Timed Get Up and Go Test Deficit noted □ Score: _____ sec. Assistive device □ Yes:_________ □ No: Comments:______________________________ □ < 10 Sec. – freely mobile □ < 20 sec – mostly independent □20-29 sec. –varied mobility □> 30 sec. impaired mobility Single Leg Stance Test Deficit noted □ Age Dominant Non-dominant 60-64 38 sec. 34 sec. 65-69 24 sec. 24 sec. 70-74 18 sec. 20 sec. 75-79 11 sec. 12 sec. 80-86 11 sec. 10 sec. Score: Dominant score: Non-dominant score: Modified Falls Efficacy Scale □ N/A Deficit noted □ Note: If stopped performing activity because fear of falling score a “0” If stopped performing activity purely because of physical problem, leave item blank, do not score ACTIVITY no confidence fairly confident complete confidence 1.Get dressed and undressed 0 1 2 3 4 5 6 7 8 9 10 2.Prepare a simple meal 0 1 2 3 4 5 6 7 8 9 10 3Take a bath or a shower 0 1 2 3 4 5 6 7 8 9 10 4Get in/ out of a chair 0 1 2 3 4 5 6 7 8 9 10 5Get in/ out of bed 0 1 2 3 4 5 6 7 8 9 10 6 Answer the door or the telephone 0 1 2 3 4 5 6 7 8 9 10 7 Walk around the inside of your house

0 1 2 3 4 5 6 7 8 9 10

8 Reach into cabinets or closet 0 1 2 3 4 5 6 7 8 9 10 9Light housekeeping 0 1 2 3 4 5 6 7 8 9 10 10 Simple shopping 0 1 2 3 4 5 6 7 8 9 10 11 Using public transportation 0 1 2 3 4 5 6 7 8 9 10 12 Crossing roads 0 1 2 3 4 5 6 7 8 9 10 13 Light gardening or hanging out the wash

0 1 2 3 4 5 6 7 8 9 10

14. Use front or rear steps at home 0 1 2 3 4 5 6 7 8 9 10 Average Score : (Normal healthy adults mean average 9.7 )


CARDIOPULMONARY/ENDURANCE TESTING Deficit noted □ Resting : Respirations:______ per/min post activity : Respirations:_____ per/min Heart rate: _____ per min Heart rate: ____ per/min 02 sats: _____ % 02 sats:_____ % Gait speed: ______ ft/sec ( Norms- 3.9-4.5 ft/sec.) Comments: INSTRUCTIONS/SKILL PROVIDED CARE COORDINATION/DISHARGE □ Safety □ Exercises □ Pressure ulcer prevention □ Gait training/Tests □ Diabetic foot care □ Home exercises □ Balance skills/Tests □ Cardiac precautions

□ Physician □ SN □ OT □ ST □ MSW □ CNA □ Patient/Family □ Case manager □ Other:_________________

HOME BOUND STATUS. PROBLEMS IDENTIFIED □ Needs assist with all activities □ Residual weakness □ Severe SOB, SOB upon exertion □ Requires assist to ambulate □ Vision □ Unable to safely leave home unattended □ Dependent on assistive device □ Medical restrictions □ Confusion, unable to go out of home alone

□ Decreased independence with transfer □ Unable to safely and independently negotiate stairs/uneven surfaces □ Decreased balance resulting in fall risk □ Decreased strength limiting functional mobility/stairs and normal gait □ Patient not on a home exercise program □ Pain limiting function □ Unsafe/unsteady gait

Comments: ORDERS: □ Needs additional PT services, see care plan for recommendations/goals □ PT Evaluation only

Patient Signature:____________________ Physical Therapist Signature:_____________________


SF - 36® Health Survey (Physical Functioning Score (PFS): TO BE COMPLETED BY THE PATIENT Name: ____________________________________ Date: __________________________

A Physical Functioning raw score of (21) is converted as follows: (21) – 10) ---------------- X 100 = 55 20 PRE PROGRAM: SF-36 PF Score: _______ POST PROGRAM: SF-36 PF Score: _______

The following questions are about activities you might do during a typical day.

Does your health now limit you in these activities? If so, how much?

(Please circle one number on each line.)

Activities Yes,

limited a lot

Yes,

limited a little

Not

limited at all

1. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.

1 2 3

2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.

1 2 3

3. Lifting or carrying groceries. 1 2 3

4. Climbing several flights of stairs. 1 2 3

5. Climbing one flight of stairs. 1 2 3

6. Bending, kneeling, or stooping. 1 2 3

7. Walking more than a mile. 1 2 3

8. Walking several blocks. 1 2 3

9. Walking one block. 1 2 3

10. Bathing or dressing yourself. 1 2 3


Patients name:__________________ ___ PHYSICAL THERAPY CARE PLAN

ORDERS: (Mark all applicable with an “x”) Evaluation/ Education Functional Skills Specialty Training Modalities Evaluation Gait training Teach cardiac

precautions Heat

Establish/Upgrade home exercise program

Balance training/activities

Muscle Re-education

Ice

Patient/ Family education

Teach safe stair climbing skills

Cardiopulmonary PT Ultrasound

Therapeutic education

Teach bed mobility skills

Pain management Electrotherapy

Teach hip safety precautions

Transfer training Pressure ulcer prevention

CPM management

Instruct on safety issues

Prosthetic training Wound care TENS

Teach body mechanics

Orthotic device training

Diabetic foot care Other:

Management and Evaluation of care plan

Teach safe/effective use of assistive/adapt. device

Energy conservation techniques

Other: Teach wheelchair skills

Fall prevention

GOALS ( all goals to be met within ____ weeks) GAIT □Patient to demonstrate safe gait with appropriate assistive device with _______ assist/ Independence throughout home for improved Functional mobility. □Patient will be safe with _____assist/independent ambulating up/downstairs with appropriate assistive device Entering / exiting home and within the home. □ Patient’s gait speed to increase to within normal limits of ___________ feet/sec. to decrease fall risk with dynamic activities. TRANSFERS/ BED MOBILITY □Patient will demonstrate improved bed mobility with ______ assist/independence to improve patients Functional mobility within the home. □Patient to demonstrate safe transfers with _________ assist/independence to promote improved independence.


R.O.M / STRENGTH □Patient will show improved (R), (L) L/E strength to ______/5 for safe and functional stair climbing, transfers, ADL tolerance and safety with gait. □Patient will demonstrate improved (R), (L) L/E, ROM of _________ joint to __________ of ___________for safe functional stair Climbing , transfers, ADL tolerance and safety with gait. □Patient will demonstrate improved (R), (L) U/E ROM of _________joint to____________ of __________ for improved ADL Tolerance. □ Patient will demonstrate improved (R),(L) U/E strength to _______ /5 for improved ADL tolerance. BALANCE/ FUNCTIONAL MOBILITY □Patient will exhibit improved TUG score to _________(sec.) to reduce fall risk with dynamic activities. □Patient will exhibit improved BERG balance score to ________ /56 to reduce fall risk with dynamic activities. □ Patient will able to single leg stance to normal limits of _________ seconds to reduce fall risk with dynamic activities. □ Patient to exhibit standing functional reach of __________ inches to reduce fall risk with dynamic activities. SUBJECTIVE/ PAIN □ Patient subjective complaint of pain will be reduced to ____ 0/10 scale to increase ability to function in daily activities. □ Patient rates confidence in fall efficacy scale to _____ on 0/10 scale average to increase confidence in performing home and Community activities. HOME EXERCISES □Patient /caregiver to demonstrate independence and compliance with a home exercise program to promote increased ability and safety with transfers, ADL’s and gait. Frequency and Duration: ___________OR □ When goals met. OR □ Patient no longer homebound Rehab potential: □ Excellent □ Good □ Fair □ Poor Discharge Plan Discussed with: □ Patient/Family □ Case manager □ Physician □Other:_______ Equipment/Supplies needed:_________________________________________________ Care Coordination: □ Physician □ PT/PTA □ RN □ OT □ST □ LSW □ Other:

Plan of Care Developed by:(Signature/Title)_______________________ Date:___/___/_____

Physician Signature:______________________________ Date:__/___/______


Rehabilitation and Exercise Following Spine Surgery

Spine surgery is a major undertaking, and rehabilitation is an important part of helping patients gets the most possible benefit from their surgery. Essentially, rehabilitation (physical therapy, exercise) can help patients recover from spine surgery as quickly and completely as possible.

One-on-One Training after Spine Surgery

The therapist will typically develop a training program tailored for the patient, taking into account the patient’s specific surgery, body type and tissue conditions.

Therapists focus on muscle facilitation with areas where the muscles may need special retraining to gain strength and provide stability following the back surgery. This type of exercise therapy may focus on:

• Muscles in the incision area

• Muscles that may have been weakened by nerve problems before the surgery

• Small muscles that work around each vertebra and help stabilize the spine. Most people (even those without spine problems) do not use these muscles very often. However, if these small muscles are trained properly, they can provide excellent stabilization that can protect the spine and protect the newly operated area to prevent future problems.

Individualized physical therapy may also help with areas where the patient’s mobility and flexibility has been limited by spine surgery. Many spine patients have problems with restrictions in their hips or shoulders or other areas of the spine. In these cases, the therapist can help the joints and the muscles involved regain the movement in relation to an individual’s body type and physical activities, and will work in the best way with the newly operated spine.

Education about Exercise following Spine Surgery

With one-on-one physical therapy sessions, patients have plenty of opportunity to ask questions of the therapist. Therapists can explain exactly what changes have occurred as a result of the patient’s specific surgery, and what can be done to maximize the benefits from that surgery.

Often, if the therapist doesn’t know the answer to a question, he or she can speak with a spine surgeon to get the answer or use the “know your back” patient education portal.


www.knowyourback.org/Pages/Brochures/Default.aspx

Therapists will encourage patients to ask as many questions as possible. Any patient’s success in recovery from spine surgery depends on his or her willingness to work hard at home as well as with the therapist. Ideally, the surgery will take the patient a great deal of the way on the road to recovery, and then the patient and therapist team can work together to make the recovery the best possible.

Lumbar Stabilization, Therapeutic Exercise Foundation (Strengthens the muscles on the lower back and abdomen)

In the immediate post surgical spine care and rehabilitation process, the primary focus is on Lumbar Stabilization.


http://www.knowyourback.org/Pages/Brochures/Default.aspx

Exercise Progression The lumbar stabilization rehab protocol, progresses from the contraction of “5 by 10” second holds of the multifidus and the transverses abdominus movement patterns, to level 1, and level 2 therapeutic stabilization exercises. The exercise progression indication consists of a patient achieving perfect form in each movement pattern, maintaining contractions for 10 seconds for 5 sets. The “Target” of “5 by 10 second holds” is an appropriate starting point three times a week before progressing to higher levels of motor patters, level 1, and level 2. Level 1 exercise is generally fully supported so that the patient can concentrate on learning and repeating muscle recruitment. Level 1 focuses on obtaining trunk and spine stabilization strength and endurance. Level 2 exercises require the patient to maintain stability in the spine during other movements challenging balance, increasing limb movement, and weight bearing. Level 3 exercises are in a quadruped position with hands and knees on the ground. This requires the patient to not only balance but handle a significant increase in weight bearing. Progression also involves less support for the trunk, greater range of limb movement, and greater speed of movement.

‘Neutral Spine’ and ‘Neutral Zone’ The cornerstone of enhancing neutral spine mental awareness is to recognize the functional limits of the spine and to stay within those limits. An optimal neutral spine position is asymptomatic, is able to be controlled, and is one that maintains the normal lumbar curve. This is in contrast to asking a patient to rigidly maintain a particular lumbar position at all times, which is impractical. Maintaining and attending to a neutral spine posture requires neuromuscular skill allowing for adjustment to loads. The arc of motion within available spinal range of motion in which there is minimal internal resistance from passive or oseteo-ligamentous structures has been termed by Panjabi as the neutral zone. (The neutral zone is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column.) However, with surgery, the neutral zone expands and muscle control decreases. There exists, then, a relationship between increased injury risk and decreased stability. Maintenance of stiffness within the neutral zone is closely linked to muscle control and particularly that of the multifidus. As described by Panjabi, muscle function is one component of the active subsystem responsible for spinal stiffness.


Specific localized exercise increases cross sectional area of the multifidus, and this may have a role in not only the acute management of low back pain but also in decreasing the risk of secondary dysfunctions as well as recurrence of low back pain. Multifidus atrophy is changeable, and recovery is more rapid and complete with the performance of specific exercises.

Integrating Exercise Therapy with Stabilization Mechanisms The clinical usefulness and feasibility of introducing low intensity exercises (% of maximal voluntary contraction) while maintaining a neutral spine is based not only on the fact that these movements will serve to target spinal stabilizers but that these movements will be better tolerated at the onset of therapy. An adequate hold time is necessary to again call upon the tonic role of stabilizers. The “Target” of “5 by 10 second holds” is an appropriate starting point. The imperativeness of establishing primary control of segmental stabilizers, particularly the “multifidus” the “transverses abdominus” and pelvic floor muscles, in order to provide for stability, cannot be underestimated.

Training for Muscular Stabilization http://youtu.be/mRyev39P0ZI / http://youtu.be/XBDz6YUz7xk Isolated contraction of the transverses abdominis is taught by a gentle drawing in or “hollowing” of the lower abdominal area. Inward displacement of the anterior abdominal wall or “hollowing” is primarily the result of transverses abdominis contraction. A qualitatively ideal response is one in which the “hollowing” is performed without movement of the spine and without substitution including using the breath, performing a pelvic tilt, depressing the rib, etc. Co-contraction of the multifidus and the transverses abdominis is facilitated by activation of pelvic floor muscles. The anatomical intimacy of the abdnominal and pelvic floor muscles is predictive of coordinated muscular efforts during tasks that challenge postural stability. To train for stability, at some point through the continuum, efforts are to focus on the multifidus and transverses abdominis with progression into introducing motor patterns that require synchronicization.


http://youtu.be/mRyev39P0ZI

http://youtu.be/XBDz6YUz7xk

Level One Lumbar Stabilization Exercises


Level Two Lumbar Stabilization Exercises


Level Three Lumbar Stabilization Exercises


Level Four Lumbar Stabilization Exercises


Walking After Back Surgery

A walking log will be tracked by the therapists and eventually given to the patient with the Home Exercise Program at the time of discharge from home health care.


PT Spine Quick Reference Guide (HEP)

Level-1 Level-2 Level-3, Post Operation 3-6 Months

Arms extended, chair squats: 3 sets, 5-10 Reps Chair hamstring stretch: 3 sets, 10-30 second hold


About The Instructor Roger K. Campbell, M.S., CET, MFT-c.

Roger is committed to the continuing education of health care professionals as a enthusiastic instructor and subject matter expert for the American College of Sports Medicine.

Campbell's greatest passion is working for the functional restoration and independence of medically complex patients. While serving with the University of Utah's Lung Transplant program in the 90’s, Campbell realized that greater restorative measures could be implemented to improve the functional independence of patients, and he set his focus on rehabilitation program development. Campbell spends his best energies developing, implementing, and promoting specialized rehabilitation programs.

Roger started his exercise science career in 1985 as an Army Master Fitness Trainer, where he physically prepared troops for combat readiness. With the GI Bill, Campbell obtained a Bachelor of Science Degree in Exercise Science from Utah State University, followed by a Master of Science Degree from the University of Utah, in Clinical Exercise Physiology.

Roger Campbell, M.S. CET, MFT-c [email protected] www.medbridgeeducation.com/courses/details/cancer-rehabilitation www.medbridgeeducation.com/about/instructor/roger-campbell


http://www.medbridgeeducation.com/courses/details/cancer-rehabilitation

http://www.medbridgeeducation.com/about/instructor/roger-campbell

Course Evaluation Roger K. Campbell, M.S., CET, MFT-c. The purpose of this evaluation is to gather input so that we may improve this course and how it is taught and therefore improve learning. We are the only ones looking at your responses, and we will report back to you on the feedback received if you desire, you may email us at: [email protected] 1. What are the strongest features of this course and of our teaching? In other words, what contributes most to your learning experience? 2. What specific suggestions do you have for changes that we can make to improve the course or how it is taught? 3. Is the pace of the course: (Too Fast) (Just Right) (Too Slow)


Glossary

-A-

Acute: Suddenly occurring. Serious, severe or painful.

Allograft: Tissue or bone harvested from cadavers or deceased individuals. In the case of spine surgery, usually refers to bone used for grafting procedures.

Annulus Fibrosis: The tough outer portion of the intervertebral disc, made of circular layers of collagen fibers that surround the soft inner core, nucleus pulposus.

Anterior: Front. Anterior approach in spine surgery refers to an approach to the spine from the front.

Arthroplasty: The surgical procedure of reconstruction and replacement of a diseased or damaged joint, using a prosthetic. This is done to alleviate pain, while seeking to restore normal function of the joint.

Autograft: A bone graft taken from one part of a patient’s body and used for fusion in another part of their body. The advantage of this procedure is the high probability of successful bone fusion.

-B-

Biomechanics: The study of the mechanics of the human body and the affects of internal and external forces on the skeletal structure. (See: Kinesiology)

Bone Graft: Bone used in fusion surgery to promote spinal fusion.

-C-

C: Cervical. The letter C followed by a number identifies a specific vertebra in the cervical spine. For example, C3 is the third vertebra in the cervical spine. It is comprised of the first seven vertebrae of the spine- C1-C7.

Cervical: The neck region of the spine, it is comprised of seven vertebrae - C1-C7.

Chronic: Persistent or lasting a long time, and in the case of back pain, typically referring to conditions lasting longer than 3 months.

CNS: Central nervous system.

CT: Computerized tomography, commonly known as a CAT Scan; a diagnostic imaging test.


-D-

Decompression: In spine procedures, refers to the surgical removal of bone or tissue to relieve pressure on adjacent nerve roots or the spinal cord.

Degenerative Disc Disease (DDD): Not a disease, but rather a catchall term used to describe degenerative changes in the intervertebral disc(s) due to aging and wear-and-tear, which result in chronic pain and restricted movement.

Disc: Refers to the intervertebral disc, a combination of strong connective tissues that hold one vertebra to the next, and acts as a cushion between each vertebra. It is made of a tough outer layer called the annulus fibrosis and a gel-like center called the nucleus pulposus.

Discectomy: Surgical procedure in which part or all of a herniated disc is removed.

Discography: A procedure that uses a needle to inject dye into the nucleus of an intervertebral disc to determine whether the disc is the source of a patient’s pain.

DJD: Degenerative joint disease, also called Osteoarthritis, refers to the degradation or breakdown of cartilage, which provides cushion between bones and joints. Results in bones rubbing together, causing pain, swelling and loss of joint motion.

-E-

Electromyography (EMG): A test used to determine the function of the peripheral nerves and nerve roots, involving placement of tiny needles in muscles and providing an electrical stimulus that can be monitored for changes that reflect the function of the connection between the nerve and muscle.

Epidural Steroid Injections: Injection of corticosteroid medications into the epidural space (the area around the spinal nerves) to reduce painful inflammation of the nerve and disc.

-F-

Facet Joints: The paired joints at the back of the spine that connect the discs. Also known as zygapophyseal joints or simply z-joints. These joints give the spinal column stability and allow for movement.

Facet Injection: Injection of steroids and local anesthetic into the facet joints to determine if they are the source of pain, or to reduce pain and inflammation in the area of the facet joints.

FDA: Food and Drug Administration. The U.S. government consumer protection agency that promotes and protects public health by helping ensure safe and effective products reach the market in a timely manner, and by monitoring products for continued safety after they are in use.

Fluoroscopic Guidance: Use of radiologic imaging to assist in the placement of instrumentation for invasive diagnostic or surgical procedures.


Fusion: A surgical procedure performed to eliminate movement at painful or unstable spinal segments. During the procedure, bone is grafted across a section of the spine where it grows together - thereby fusing the area. Spinal fusion is often used to treat degenerative disc disease and is also used to treat scoliosis, kyphosis, spinal fractures and tumors.

-H-

Herniated Disc (HD): Occurs when the nucleus pulpous (gelatinous center) of an intervertebral disc bulges out through a tear in the outer fibrous ring, this is caused by age, wear and tear or injury. Also known as a slipped or ruptured disc.

Herniated Nucleus Pulposus (HNP): See Herniated Disc.

-I-

Instability: When vertebrae move beyond their normal range of motion. Can be the result of an injury, degenerative disease or congenital condition.

Interbody Fusion: Grafting bone in the space between discs for the purpose of fusing two vertebral segments.

-K-

Kinesiology: The study of muscles and body movement. (see: biomechanics)

Kyphosis: Exaggerated forward rounding of the upper spine. May give rise to conditions commonly known as humpback, hunchback or Pott's curvature.

-L-

L: Lumbar. The letter L followed by a number identifies a specific vertebra in the lumbar spine. For example, L3 is the 3rd vertebra in the lumbar spine. L3-4 would refer to the disc (or disc space) between the L3 and L4 vertebrae. There are five bones in this part of the spine- L1-L5.

Laminectomy: Surgical procedure removing the shingle-like portions on the back of a vertebra (lamina), which protect the spinal cord and nerve roots, to relieve pressure on the underlying spinal cord and nerve roots.

Laminotomy: Surgical procedure removing a small portion of the shingle-like elements (lamina), which protect the spinal cord and nerve roots, to relieve pressure on the nerve roots.

LBP: Low back pain, also known as lumbar back pain.


Lordosis: Exaggerated inward curving of the spine, usually in the lumbar region. Also known as swayback or saddle back.

Lumbar: The lower back region of the spine; it is comprised of five vertebrae- L1-L5. This is the most common area for back pain.

-M-

Microdiscectomy: A surgical removal of small portions of disc material, or a herniated portion of the disc, performed with a microscope for precise visualization during the procedure.

Minimally Invasive Surgery (MIS): Surgery done through multiple small incisions, rather than through a large, open procedure.

MRI: Magnetic resonance imaging; a diagnostic imaging test.

Myelitis: Spinal cord inflammation.

Myelopathy: Spinal cord disorder that commonly causes weakness or loss of function in the lower extremities, and spasticity in the upper extremities.

-N-

NASS: North American Spine Society. A multidisciplinary organization for spine care professionals and researchers that advances quality spine care through education, research and advocacy.

NSAIDs: Non-steroidal anti-inflammatory drugs. Medications used to reduce swelling and inflammation. Examples of NSAIDs are: aspirin, ibuprofen, naproxen and a variety of prescription drugs.

-O-

Osteophytes: Bone spurs. They can form on any bone, but typically form in joints.

Osteoporosis: A condition in which the bones lose density and become more porous and prone to fracture, usually age-related.

Orthosis: Brace.

-P-

Pedicle: Projection of bone from the back of the vertebra that help form the ring around the spinal canal.

Percutaneous: Passage through the skin, by needle or other object.


Percutaneous Lumbar Discectomy (PLD): The removal of bulging disc material percutaneously through a large bore needle inserted into the disc space. Also known as percutaneous microdiscectomy.

PMMA: Polymethyl methacrylate. A material used as bone cement for orthopedic and spine surgery.

Posterior: Rear. Posterior approach in spine surgery refers to an approach to the spine from the backside.

Posterior Lumbar Interbody Fusion (PLIF): Spinal fusion technique in which a disc is removed through the back of the spinal canal and a bone graft is inserted in the intervertebral space, also through the back.

Pseudarthrosis: When a solid fusion is not obtained after fusion surgery. This term can also refer to a fractured bone that has not healed.

PT: Physical therapist or physical therapy.

-R-

Radiculopathy: Impairment of a nerve root along the spine, usually causing radiating pain, numbness, tingling or muscle weakness that corresponds to a specific nerve root.

ROM: Range of motion.

-S-

Sacrum: Part of the tailbone just above the coccyx and below the lumbar spine.

Sciatica: Compression or irritation of the sciatic nerve. Can result in pain, numbness, tingling or weakness.

Scoliosis: Abnormal sideways curvature of the spine.

SI: Sacroiliac. The joints (one on each side) between the sacrum at the midline and the iliac wings, which form part of the pelvic ring.

Spina Bifida: Congenital (birth) defect of the spinal column, where a hole in the vertebra leaves the spinal cord and nerves exposed.

Spina Bifida Occulta: A congenital defect of the spinal column where the lamina fail to come together completely at the midline. In this form, there are no exposed neural elements, therefore, this is usually an incidental finding without clinical findings associated.

Spinal Cord Stimulation (SCS): Electrical device implanted in the spine to control chronic pain.

Spinal Stenosis (SS): A narrowing of the spinal canal, usually in the lumbar or cervical spine. Can cause compression of the spinal canal or nerve roots.


Spondylolysis: The breakdown of a vertebral structure. A fracture (crack) that occurs in the "pars interarticularis", the small portion of bone joining the facet joints in the posterior of the spine.

Spondylolysis, Degenerative: When a vertebra slips forward over the vertebra below it, as a result of arthritis of the small joints of the spine and degeneration of the discs.

Spondylolysis, Isthmic: When a vertebra with a crack in the "pars interarticularis"(the small portion of bone joining the facet joints in the posterior of the spine) slips forward over the vertebra below it.

Spondylolisthesis: When a vertebra in the lower portion of the spine slips forward and onto the bone below.

-T-

T: Thoracic. The letter T followed by a number identifies a specific vertebra in the thoracic spine. For example, T3 is the 3rd vertebra in the thoracic spine. There are twelve bones in this part of the spine- T1-T12.

Thoracic: Mid-upper back region, it is comprised of twelve vertebrae- T-T12.

-V-

Vertebrae: Bones that make up the spine.


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