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TLIF/POSTERIOR LUMBAR FUSION POST-OPERATIVE
REHABILITATION GUIDELINE
- No NSAIDs for 6 months
- No driving while on narcotics
- No scar mobilization for 3 months
- No jog/run/horseback riding for 6 months
- Education booklet to patient before surgery (smoking cessation)
- All patients progress at different rates...progress as appropriate, with goal completion
Phase 1 (POD 1 - 6 weeks)
- Brace, if needed, is patient specific
- Typically needed for those with poor bone quality, smokers, sustained spinal fractures
- Multi-level fusion may require longer wear
Focus:
- Mobilization, correctly performing ADLs
- Putting shoes on, correctly picking items off ground, etc
- Ambulation, endurance, posture
- Begin progressive walking program
- Correct usage of assistive device
Phase 2 (6 weeks - 3 months)
- Begin regimented OP PT (2-3x/week) for 6-8 weeks (12-24 visits)
- Give ODI, FABQ at initial evaluation
- FABQ at 6th visit as well
Goals:
- ↓ pain, 0-2/10 pain at rest
- Improve scar mobility
- Maintain erect posture throughout 80% of the day
- Reestablish neuromuscular control of the lumbar stabilizers
- Volitional contraction of TA and lumbar multifidi for 5 x 5 sec
- Improve LE strength & mobility
- Demonstrate appropriate functional movement within precautions
- Continue progressive walking program
- Independent with HEP
- Progress exercises once patient demonstrates proper form/technique and control of neutral spine with each
repetition
- D/C brace at 12 weeks or surgeon’s orders
Focus:
- Initiate aerobic conditioning (gentle, progressive)
- Ambulation, endurance
- Progress toward discontinuing assisted devices
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- Treadmill, track, recumbent bike
- Continue to walk within tolerance with progressive walking program
- Strengthening (legs core back)
- Can use light weights, pulley system, resistance bands
- Isometric lumbar stabilization exercises with trunk ext/flex/lateral flexion
- 15s → 45s x 3
- Lumbar stabilization exercises (with trunk co-contraction) – 2 x 10,15,20
- 1. Hook-lying pelvic neutral (hip at 45°): marches → SL heel slide → leg lift c knee ext.
- 2. dying bug: alt. UE → alt. LE → alt. opposite UE/LE
- 3. Bridges
- 4. birddog: alt. UE → alt. LE → alt. opposite UE/LE
- 5. pelvic tilts (all directions)
- LE strengthening exercises (maintain neutral spine) – 2 x 10,15,20 (progress c resistance):
- 1. wall squats
- 2. supine abdominal crunch (not a sit-up)
- 3. Hook-lying bent knee fall outs
- 4. Side-lying hip abduction/clamshells
- 5. standing hip extension
- Stretching, LE flexibility
- Bilateral LE stretching 3 x 30s (gastoc/soleus, hamstrings, hip flexor)
- Nerve glides 2 x 10...15...20
- Balance, POSTURE, Gait training
- Neuromuscular activation of lumbar stabilizers (multifidi, TA)
- Diaphragmatic breathing
- Abdominal isometrics, hollowing of TA and lumbar multifidi
- Drawing in maneuver and VC for volitional lumbar multifidi contraction
- Maintain neutral spine, initiate pelvic tilts in all directions
- Appropriate lumbar lordosis
- + / - pool therapy
- Swimming within tolerance
- Functional movement for home/work
- Proper body mechanics
- Bend with knees when reaching toward floor
- Shift weight, don’t twist body
- Lift slowly, close to body
- Bring feet/leg up to self when donning/doffing shoes, socks
- Scoot to front of chair when standing
- Education/review on precautions, anatomy/biomechanics, surgical procedure, prognosis
- Control pain/inflammation
- ice/modalities
- Manual
- Grade I-II joint mobilizations above/below surgical site for pain modulation
- Soft tissue mobilization for hypertonic paraspinal muscles
- Facilitate healing of incision (watch for increased redness/drainage/swelling)
Suggested Components for Daily HEP:
- Pain management PRN
- Appropriate stretches
- LE strengthening with neutral spine
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- Postural awareness, pelvic tilts
- Abdominal hollowing in isolation and with extremity movement
- Progressive walking program as tolerated, monitoring steps
- See end of protocol
Avoid:
- Lifting, bending, twisting > 20 lbs until 3 months post-op (BLTs)
- Includes yardwork, pushing/pulling
- Sitting prolonged periods - encourage position changes 30-45 minutes
- Sit with back support, feet flat on floor, knees level with hips
- Lotions/creams, submerging incision underwater until fully healed
Other considerations/precautions:
- Brace wear as indicated by surgeon
- Consult doctor for return to driving, return to work
- May be shorter return for sedentary jobs
- Sleeping
- Supine with pillow under knees
- S/L with pillow between knees
Phase 3 (3 - 6+ months)
- ODI + FABQ at discharge
Goals:
- Progress to return to baseline standing/walking duration, distance
- Maintenance of trunk co-contraction throughout therapeutic activities
- Volitional contraction of TA and lumbar multifidi for 7 x 7 sec → 10 x 10 sec
- Maintenance of neutral spine during therapy interventions
- Improve trunk and LE strength
- Achieve functional ROM
- Demonstrate proper ergonomics and work simulation
- Able to tolerate work simulation activities without increase in symptoms
- Verbally understands return to work progression
- Continue, ultimately complete progressive walking program
- 0-2/10 pain with activity → 0/10 pain with all/most activities
- Independent with HEP
- Achieve ODI MCID
Focus:
- Progress endurance
- Aerobic conditioning
- walking/treadmill
- Progress to elliptical
- Trunk + LE mobility, flexibility
- Aim for mid-end range ROM by 3-4 months
- Quadruped rocking, cat/camel, prayer stretch
- Bilateral LE stretching
- Strengthening
- Increase weight limit by 5 lbs every other week as tolerable
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- Muscle Strength of lumbar stabilizers
- Dynamic exercises
- with trunk co-contraction – 2-3 x 10,15,20:
- 1. Hook-lying pelvic neutral (hip at 90°): marches → SL heel slide → leg lift c
knee ext.
- 2. sitting or standing pelvic neutral: alt. UE → marching → marching c alt. UE
- 3. SL bridges or DL c marches
- 4. prone and side-lying planks (on knees: 5-10 sec)
- 5. standing isometric core resistance c Theraband
- 6. standing pelvic neutral: shoulder ext, hor. abd., row, D1/D2 c Therband (bil →
uni)
- Further progressions - 2-4 x 10, 15, 20
- bridges on Dynadisc or BOSU
- upward/downward chops (cable column)
- prone and side-lying planks (off knees: 5-10 sec)
- walkouts/rollouts on stability ball
- cable column resistance walking (close to body → away from body or OH)
- prone superman’s
- LE strengthening exercises (maintain neutral spine) – 2-3 x 10,15,20 (progress c resistance)
- 1. stability ball wall squats
- 2. standing hip abduction and extension
- 3. side stepping
- 4. lunges (SP and FP)
- 5. SL deadlifts
- Further progression (2-4x)
- squats (DL → SL)
- SL deadlift on Dynadisc or BOSU
- lateral band walks
- lunges (add TP)
- stability ball H/S curl
- Core strengthening (planks)
- Facilitate neuromuscular re-education
- Abdominal hollowing of TA, lumbar multifidi
- Balance, progressing as needed
- DL → SL, EO → EC, no UE mvmt → UE mvmt, stable → unstable surface
- High level
- Rebounder toss, medicine ball rotations on stability ball, etc
- Pain/inflammation reduction
- Joint mobilization (grades I-II) above/below surgical site for pain modulation
- ice/modalities
- Light work simulation activities → full duty work simulation
Suggested Components for Daily HEP:
- Stretches, ROM (progress to maintenance therapy)
- Trunk, LE strengthening, stabilization (progress to maintenance therapy)
- Proper lifting and functional movement
- Progressive walking program
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Recommendations for return to work based on job type:
Work Type:
Return to Work:
Sedentary (<10lbs) or Light (frequently 10lbs,
occasionally 20lbs)
After 8-14 weeks, with limited sitting duration for 30
min at a time for 6 weeks
Moderate (frequently 20lbs, occasionally 50lbs)
At 10-16 weeks, patient may return to light duty if
available – no lifting >10lbs
At 14-20 weeks, return to full duty – no lifting >25
lbs
Heavy (frequently 50lbs, occasionally 100lbs)
At 10-16 weeks, patient may return to light duty if
available – no lifting >10lbs
At 14-20 weeks, moderate duty – no lifting >25lbs
At 22-28 weeks, return full duty
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Progressive Walking Program, begin POD 1
AIM: MODEL OF PROGRESSION:
10,000 steps/day, if:
age under 65 years,
healthy and no restrictions
to increase physical activity
1. If baseline level <5,000 (sedentary), number of
steps is increased 15% every other months until
the target level is reached.
2. If baseline level 5,000–7,499 (”low active”),
number of steps is increased 10% every other
months until the target level is reached.
3. If baseline level 7,500–9,999 (”somewhat
active”), number of steps is increased 5% every
other months until the target level is reached.
4. If baseline level >10,000 (active), this level is
maintained or number of steps is increased 5%
every other months until 12,500/day (”highly
active”) is reached.
7,500 steps/day, if:
age >65 years
and/or chronic diseases
and/or some restriction to increase physical activity
1. If baseline level <4,250, number of steps is
increased 15% every other months until the target
level is reached. In later phase, this level is
maintained or a new goal is set.
2. If baseline level >4,250, number of steps is
increased 10% every other months until the target
level is reached. In later phase, this level is
maintained or a new goal is set.
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Reviewers:
Dr. Andrew Grossbach, Neurological Surgery, The Ohio State University Wexner Medical Center
Dr. Jonathan Karnes, Orthopaedic Surgery, The Ohio State University Wexner Medical Center
Dr. Safdar Khan, Orthopaedic Surgery, The Ohio State University Wexner Medical Center
Dr. Stephanus Viljoen, Neurological Surgery, The Ohio State University Wexner Medical Center
Dr. Elizabeth Yu, Orthopaedic Surgery, The Ohio State University Wexner Medical Center
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