Rehabilitation Department Scoliosis Protocol

The following protocol for physical therapy rehabilitation is based on the “typical” patients seen at Springfield Orthopaedic and Sports Medicine Institute for scoliosis. Deviations from the protocol are dependent on prior level of function, general health of the patient, equipment available, goals of the patient, and specific orders written on the prescription. It is the treating therapist’s responsibility along with their treating physician guidance to determine the actual progression of the patient within the protocol guidelines.

Three important concepts throughout the scoliosis physical therapy protocol are maintenance of neutral spine, stabilization and development of cardiovascular endurance. Stabilization can be defined as a balance between strength, flexibility, muscular endurance, coordination, and aerobic capacity which makes it possible to maintain neutral spine during static and dynamic loading. Neutral spine can be thought of as a position between spinal flexion and extension that is most comfortable for the patient and produces the least amount of pressure on the disc. It is vital that the fusion process has begun prior to the progression of lumbar functional ROM. Fusion usually begins between 10-12 weeks and is confirmed only through X-ray. The fusion process continues for 12-24 months. It is also important to note that variations may exist in the type of lumbar fusion surgical approach used and limitations are dependent on the particular surgical approach used.

Once the patient can demonstrate proper stabilization without cueing, a progression of exercises to further develop and improve stabilization should be considered. It is important that proper stabilization be achieved with each attempted exercise prior to progressing to moderate/advanced stabilization exercises. Many exercises are described in the protocol, however, the list is not exhaustive and other options may be incorporated as needed. The treating therapist will use his/her professional judgment, guided by the patient’s response and mechanical basis for achieving proper stabilization to determine when proper progression of exercises can occur.

The following clinical observations require a consultation with the referring/consulting physician: 1. Failure of incision to close or significant redness, swelling or pain in the area of incision. 2. Unexpectedly high self-reports of pain in comparison to presurgical state. 3. Loss of Bowel or Bladder function. 4. Failure to meet progress milestones according to protocol “guidelines” as they may be modified by clinical judgment with consideration given to previous presurgical state and typical progression of patients during rehabilitation. 5. Evidence of acute exacerbation of symptoms: significant increase of pain, sudden increase of radicular symptoms, and/or sudden loss of strength/ sensation/ reflexes. 6. Development of new unexpected symptoms during the course of rehabilitation.

Further information can be obtained by contacting Dr. Domingo Molina IV, at Springfield Orthopaedic and Sports Medicine. This is for information only and is not intended to substitute for sound clinical and professional knowledge.

937-398-1066 ph | springfield-ortho.com 140 W. Main St. | Suite 100 | Springfield, OH 45502 Scoliosis Protocol General Considerations: Precautions: • Decrease swelling / inflammation • Avoid range of motion until cleared by physician (4 - 5 mos.) • Prevent stiffness / soft tissue mobilization as needed • Avoid excessive loading and distraction • Increase cardiovascular fitness level • Avoid rotational activities until cleared by physician (min 4 - 5 mos.) • Begin stabilization / restrict lumbar ROM • Wear brace as instructed by physician • Pain / symptom modulation as needed

PHASE CONSIDERATIONS TREATMENTS GOALS

I. Pre- P.T. • Increase tissue tolerance to activity • Home exercise program per • Independent HEP • Increase lumbar isometric hospital discharge (given at hospital) Wound Healing and Protection tolerance • Relaxation exercises • Walking 1 mile daily (10 - 30 min.) 0 - 4 weeks • Encourage wound healing • Walking tolerance per discharge • Functional ADL for hygiene • Initiate post operative exercise instructions • Well healed surgical incision program • ADL instructions • Aerobic conditioning • Normal lower and upper extremity ROM

II. Initiation of P.T. • Flexibility of lower and upper • Neutral Spine with arm and leg • Working knowledge of body and extremities movement lifting mechanics & ergonomic Flexibility, Activity Tolerance, and • Posture and body mechanics • Light Resistive Training with neutral considerations Body Mechanics • ADL discussion spine • Single leg balance 10 sec. 3-8 weeks • Trunk isometrics • Modalities PRN for Pain • Cardiovascular tolerances of 20 to • Limit overhead activity • Activation of transverse abdominal 30 min daily 2 - 3 sessions/week • Pain modulation if needed muscle with neutral spine • Dynamic standing and/or sitting • Teach scar mobilization • Balance and Proprioceptive activity tolerance of 10 to 30 min. • Positional tolerance Training • Level 1 stabilization • Cardiovascular training/ • Maintain neutral spine with conditioning activation of transverse abdominal • Body Mechanics for ADL muscle x 1 min. • Treadmill

III. Advanced P.T. • Body mechanics, posture emphasis • Activity / Job Specific Training • Balance drills 20 seconds with exercises, postural drills • Advanced stabilization exercise • Cardiovascular tolerance of 30 to Strength, Balance Activities, • Increased U/E and L/E strength with neutral spine 40 min. Cardiovascular Training, and with stabilization • Advanced posture and body • Dynamic Sitting/Standing Advanced Stabilization • ADL review for problem areas mechanics tolerance of 15 to 60 min. 8 - 20 weeks • Soft tissue mobilization as indicated • Advanced cardiovascular activities • Level 2 stabs • Return to work assessment/ (nordic track, precor) • Supine “dead bug” 30 seconds 2 - 3 sessions/week investigation • Supported Bike neutral spine • Lumbar mobility per physician • Strength training with neutral spine • Transitional squat drill with ball direction • Wall slides • Pain modulation if needed • Strength training tolerance of • Vocational counseling if needed 15 - 30 min.

IV. Functional Rehabilitation • Progress to independent program • Independent program with • Independent with all exercises and • Restrictions limited to safety issues integration of posture, strength, home/gym program Recreational Activities, Return to • Encourage cardiovascular, flexibility, and lifting considerations • Return to gainful employment/ Work, and Independent Program strength, and flexibility issues • Emphasize proper body school activities 20 - 25 weeks • Progress to pre-morbid activities mechanics and ergonomic • Able to incorporate safe body considerations mechanics and ergonomic • Begin ROM for spine information to promote a back-safe lifestyle

937-398-1066 ph | springfield-ortho.com 140 W. Main St. | Suite 100 | Springfield, OH 45502 Scoliosis Activity Restrictions & Home Exercise instructions

Activity Restrictions

No bending, twisting or overhead reaching until authorized by your surgeon, use your legs not your Range of Motion back to bend down.

Avoid lying on stomach. Utilize side lying with pillow between the knees or on back with pillow Bed Positioning behind knees.

Bed Mobility Utilize the log rolling method to go from lying to sitting or sitting to lying. (See Attached)

No driving for 2 weeks then consult your Surgeon. After 2 wks drive only short interval of 20 minutes Driving or less. Do not drive stick shifts without consulting your Doctor.

Do not lift anything heavier than 5 lbs for 4 weeks then progress slowly. Keep objects close to body. Lifting No overhead and nothing that causes straining until authorized by your surgeon.

No sitting for more than 20 minutes intervals for 4 weeks then slowly progress to 30-40 minutes as Sitting tolerated after 4 weeks. No unsupported sitting.

None for 4 weeks. Assume the least exerting and most comfortable positions. Avoid flexing/ Sexual Activity extending/rotating lumbar region.

None for 1 month because of posture and submersing the incision, then only for short Tub Baths: durations. Do not use extremely hot water (skin should not turn red).

Household Chores Avoid for 6 - 8 weeks, slowly progress as you begin.

Yard Work Wait at least 3 months, then begin slowly and take frequent breaks.

If issued by Doctor, Corset brace should be worn when in sitting, standing, walking positions for added support, but will not prevent spinal motion. Continue use until your Doctor tells you to wean Braces Wearing off brace. Sometimes, hard braces (TLSO) are issued to patients, which must be worn at all times except when lying down.

Take it easy the first 24 hours at home!!! Rest as much as possible

Walking Program – Walk as much as your pain will allow at a comfortable casual pace • Choose a safe, paved area that is flat and firm • Gradually increase total walking time to 45 minutes or greater per day by 1 - 2 months post surgery. Be attentive to your body’s painful “warning signals” which may indicate over activity or undue stress. Discontinue any activity if: They cause persistent pain in the trunk, arms, back, buttocks, or legs during or following the activity, or they cause an abnormal increase in morning pain or stiffness (muscle soreness is okay, pain similar to prior to surgery is not okay). Begin the exercises on the following page on your first full day home and progress gradually as tolerated. Perform exercises in bed per instructions on the following page. These home exercises were designed to reduce chances of a blood clot following surgery and aid with mobilizing fluids in the tissues to manage inflammation and aid in the healing process. The exercises are also designed to reduce onset of muscle atrophy by maintaining strength, endurance, and mobility to prepare you for outpatient therapy. Your outpatient physical therapist will progress you through more advanced exercises when appropriate, and guide you safely back to a more normal activity level. The outpatient therapy is an essential part of your rehabilitation.

937-398-1066 ph | springfield-ortho.com 140 W. Main St. | Suite 100 | Springfield, OH 45502 Scoliosis Home Exercise Program

Perform these exercises hourly:

HAMSTRING SETS: Slightly bend your knee, press your heel down into the bed and tighten the muscle on the back of your thigh. Hold for 5 seconds. Relax, then repeat 5 times. As tolerated, bend knee further, keeping foot on bed.

QUAD SETS: With a straight leg press your knee down into the bed and tighten the muscle on the front of your thigh. Hold for 5 seconds. Relax, then repeat 5 times.

GLUT SETS: Squeeze your buttocks together gently. Hold for 5 seconds. Relax. Then repeat 5 times. Avoid arching your back

ANKLE PUMPS: Move foot/toes toward you and then down point foot away — bending at the ankle. Repeat 15 times.

937-398-1066 ph | springfield-ortho.com 140 W. Main St. | Suite 100 | Springfield, OH 45502 Perform these exercises 2 - 3 times a day:

ISOMETRIC EXTENSION: Lie on your back with arms extended at your side. Press your arms into the bed. Squeeze shoulder blades together while pressing. Do not arch your back. Hold 5 seconds. Repeat 5 reps.

SCIATIC NERVE MOBILIZATION: Lie on your back with knees comfortably bent. Bring one thigh up toward waist line with knee bent (use a towel or sheet assist if hands are unable to reach back of thigh). Slowly pump leg up and down with gentle pull at top and no hold. Perform 15 reps each leg.

TA (Transverse Abdominus) STABILIZATION: Draw or suck in navel towards the mattress without moving hips or spine. Your navel should drop not rise. It feels like zipping a tight pair of pants. Hold contraction 5 - 10 seconds then relax, perform 5 - 10 reps

Marching w/ TA STABILIZATION: Lie on back wih knees bent. Maintain TA contraction (navel to spine) throughout exercise. Bring one knee up, then return. Be sure pelvis does not rock backward or forward keeping the back relaxed. Perform 5 to 10 reps each leg.

Modified Glut / Pretzel Stretch: Lie on back with one ankle crossed over the opposite knee. Gently push out knee with arm on same side. Hold for 10 to 30 seconds based on tolerance. Perform 1 rep each leg.

937-398-1066 ph | springfield-ortho.com 140 W. Main St. | Suite 100 | Springfield, OH 45502 Log Rolling Method:

Bend both knees until you are in this position

Roll your body as a unit Keeping hips and shoulders in alignment, do not twist at trunk

Push yourself up with arms keeping hips and shoulders in alignment, do not twist at trunk

Sit Pivot Method:

Sit on car seat facing out the side of the car. Pivot body to inside of car keeping hips and shoulder in alignment, do not twist trunk

Spine_Scoliosis Protocol_PT Protocol (6-30-20)

937-398-1066 ph | springfield-ortho.com 140 W. Main St. | Suite 100 | Springfield, OH 45502