Table 5. (Cont.) Task Goal Getting dressed To instruct the patient about getting dressed with minimal loading of the spine Sitting To inform the patient about the optimal sitting posture and duration.Ifnecessary,asup- portive pillow is recommended Driving To instruct a patient on how to getinandoutofacar.The position of the seat should be discussed as well as the impor- tance of short breaks when driving over a longer period of time Taking a shower or bath To evaluate self-care at home patient’s daily routine. To ensure good compliance and motivation, it is of great importance that the exercises are simple and of short duration. Finally, the home exercise program must be customized in conjunction with the surgeon, based on the surgical procedure, the associated contraindications, and the current func- tional status of the patient ( Tables 6, 7). Postoperative Rehabilitation Chapter 22 611 Table 6. Home exercise program after lumbar surgery Exercise Goal Activation of m. transversus abdominis To increase the ability of selective transverse abdo- minis activation Coordination of m. transversus abdominis while moving the lower extremity To increase independency between active lumbar spine stabilization and movement of the extrem- ity Stabilization of the trunk muscles and strengthening of the lower extremity muscles Exercise with regard to activities of daily living (sit to stand) and body aware- ness Stretching of the gluteal muscles To increase flexibility of the gluteal muscles and gentle mobilization of the lower lumbar spine into flexion However, the therapist may provide patients with educational information regarding back care, basic body mechanics and practical tips for self-care. This can be in the form of group education, brochures and accurate internet web sites. After soft tissue healing, stretching and strengthening exercises can be intensified Approximately 3 months after surgery, biological healing is complete and exercises can be progressed as tolerated by the patient and according to the sur- geon’s protocol. Stretching and strengthening exercises can be intensified and should be performed two to three times a week [23]. In addition, it has been shown that an aerobic exercise program can be beneficial for successful rehabili- tation [3]. Depending on the intervention and pain tolerance, the patient should be as active and independent as possible, returning to most of their daily activities. If the postoperative reassessment by the surgeon at 4–6 weeks postoperatively reveals any difficulties or irregularities, the patient is referred to physical ther- apy. Depending on the patient’s presentation, the physical therapist will provide an individual treatment and management plan aiming to restore normal func- 612 Section Degenerative Disorders Table 7. Home exercise program after cervical surgery Exercise Goal Activation of the deep neck flexors To increase the abil- ity of selective deep neck flexor activation Stabilization of the cervical spine To facilitate body awareness and improve cervical posture Stabilization of the cervical spine during movement To facilitate optimal cervical posture in activities of daily living (sit to stand) tion, activity and participation. The intervention is planned with regard for the surgical procedure and is based on: loading disorder: symptoms in sustained positions movement disorder motor control disorder If the patient’scomplaints are of a loading disorder, the treatment of choice would be mobilization of possible hypomobile segments in order to restore optimal posture. Moreover, advice on posture, strengthening of impaired muscles and pain-relieving positions and ergonomics is given to the patient. In case of a rehabilitation deficit, individual treatment and management is provided after 4 –6 weeks Treatment of a movement disorder focuses on improving hypomobile move- ment segments and restoring optimal muscle extensibility. Stabilizing exercises with individual focus on the impaired muscle function and postural advice are the main management strategies for a motor control disorder. Postoperative Rehabilitation Chapter 22 613 Aftercare/Prevention Theaimofaftercareisto maximize the individual’s resumption of all ADL The aftercare period starts at around 3 months after surgery, when biological healing is complete and exercises can be progressed as tolerated by the patient and depending on the intervention. The aim of aftercare is to maximize the indi- vidual’s resumption of all functional activities of daily living including personal, social, and occupational domains. The rehabilitation program should follow the current guidelines of back and neck pain management in which physical, thera- peutic, and recreational exercises are recommended [1]. The continuation of a back- or neck-related home exercise program should be encouraged, with an emphasis on neck and trunk flexibility and strength. Aerobic conditioning should also be encouraged as the benefits to the entire body are evident [1]. Extensive evidence exists legitimizing the need for activity as compared to rest, although to date it remains unclear whether any specific type of exercise is more effective than any other [31]. Physical Rehabilitation Training If apatient still has deficits in function, activity or participation at 3 months post- operatively, a physical rehabilitation program can be started. This rehabilitation programshouldbeperformedtwotothreetimesaweekandcontinuouslyinten- sified [23]. In addition, it has been shown that an aerobic exercise program can be beneficial for successful rehabilitation [3]. Rehabilitation after spinal surgery willbebasedonthePRTsystem(physical rehabilitation training) [32]. Upon the first appointment, the patient’s need for their ADL and their loading ability will be analyzed in order to compose an individual program to eliminate the remain- ing dysfunctions specifically. The standard program progresses according to the following stages: proprioception strength endurance acceleration/deceleration training Physical rehabilitation consists of coordination, strength endurance and acceleration/deceleration training Proprioception is trained first in a motor learning approach to improve muscle coordination. This stage of the training will last 3–6 weeks on average and is underloaded, which means the patient can perform the training without fatigue in the target muscles. The strength endurance stage is then reached and the patient will progress until they can perform 8–14 repetitions under load while provoking fatigue in the target muscles. Once the patient can perform the exer- cises with the required weight for two to three consecutive trainings, the program is progressed to the next stage. Acceleration and deceleration training, which differ from strength endurance training in the rhythm of the performance, is the next stage of the training. The same exercises are implemented at an increased speed than before. This promotes further adaptation and remodeling of the con- nective tissues. Return to Work Thereturntoworkisnotcloselycorrelatedwiththeextentoftheintervention. On the contrary, confounding factors seem to play an even more important role [9, 26]. The rate of resumption of heavy work is difficult to determine and will be Return to work is key in postoperative rehabilitation dictated by the surgeon with consideration of the operative procedure and the degree of postoperative soft tissue and bony alterations. This decision will often be anecdotal and will vary from surgeon to surgeon. We recommend that the patient resumes work as soon as possible. 614 Section Degenerative Disorders Table 8. Home exercise program after lumbar surgery Exercise Goal Dead lift To stabilize the trunk during bending activi- ties Progression: dead lift in extension Front press To stabilize the trunk during upper extremity movements Bent over barbell row To stabilize the trunk in an inclined position Postoperative Rehabilitation Chapter 22 615 Table 8. (Cont.) Exercise Goal Bent over barbell row Progression: bent over dumbbell rotation Barbell rotation To stabilize the trunk during rotational activi- ties Recreational Activities Activity resumption should be as soon as possible Most studies investigating return to sports and recreational activities were per- formed on athletes [7, 36, 40]. It has been found that different factors may influ- ence the time to return to recreational activities. Among them are the patient’s preoperative health condition, age, and quality of surgery. It is suggested that patient motivation influences recovery from spinal surgery and return to recrea- tional activities [36]. Limited data assist with decision-making for return to sport after (thoraco-) lumbar fusion [40]. Some of thecriteria used to determine return to play included a solid fusion based on clinical assessment and imaging studies and full recovery as determined by near normal range of motion and normal muscular strength. Return to sport decisions must be made on an individual basis, and various factors, such as the number of levels fused, must be taken into account. Obstacles for Rehabilitation Morphological Obstacles and General Medical Obstacles Care must be taken to distinguish between procedure-specific morphological obstacles and general medical obstacles. Morphological obstacles for rehabilita- tion can occur immediately postoperatively or after a latency of a few days. It is important to emphasize the difference between persistent and new symptoms. Possible immediate postoperative complications include: neural injury (de novo) neural compression (persistent or de novo, e.g., epidural bleeding) early infection 616 Section Degenerative Disorders Late postoperative morphological obstacles for rehabilitation include: non-union late infection persistent neurological dysfunction instability (de novo or persistent) medical complications (e.g., myocardial infarction, stroke, pulmonary embolus) other comorbidities Comorbidities are frequent obstacles for recovery During the physical assessment a patient’s medical history is critical in order to identify comorbidities such as hypertension, diabetes mellitus, and pulmonary and cardiovascular diseases. These comorbidities have been linked to the need for postoperative critical care and increased hospitalization [15]. Psychosocial Obstacles Psychosocial obstacles for rehabilitation include: psychosocial factors (psychological, behavioral, social factors) [35] (see Chapter 11 ) fear-avoidance behavior [34] kinesiophobia [18] A clinical assessment of risk factors for delayed recovery is required and must include attention to psychosocial factors (Chapter 21 ). The fear avoidanc e model describes how patients avoid normal activities if they believe these activi- ties will provoke pain. Fear of movement or (re)injury, also called kinesiophobia, is associated with avoidance behaviors that increase functional disability in chronic low back pain. Kinesiophobia is an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury [33]. Treatment to reduce this fear must include cogni- tive behavioral techniques that address the perceived threat of movement or pain, in conjunction with progressive exercise and function. Work-Related Obstacles As outlined in Chapter 21 , job satisfaction has been associated with low back pain disability. Similarly, psychological aspects of work such as: occupational mental stress general job satisfaction job related resignation were shown to be related to postoperative relief of disability [26]. Recapitulation Epidemiology. Theliteratureissparseonpostoper- ative rehabilitation after spinal surgery. This lack of evidence includes not only the epidemiology but also the efficacy of postoperative rehabilitation af- ter spinal surgery. Conceptional background. Ideally, the rehabilita- tion process is initiated prior to surgery through a precise and thorough preoperative assessment. Initially an accurate diagnosis is imperative so that the physician can identify an optimal surgical inter- vention. A thorough physical examination and medical history is useful for identifying comorbidi- ties, since these have the potential to impede the rate of postoperative rehabilitation. The patient’s functional status must also be carefully scrutinized. Postoperative Rehabilitation Chapter 22 617 An international classification system, ICF, has been established for determining the impact of a condi- tion or illness with regard to human functioning and its restrictions. This system takes into account function and disability (impairment) with consider- ation of contextual factors (participation in the activities of daily living, and work and leisure pur- suits). Based on the physical and functional assess- ments, postoperative rehabilitation plans are initi- ated. The physician and patient must have an unambiguous understanding of the other’s expec- tations and the role of each of them in the postop- erative recovery. After surgery, an ongoing reas- sessment of the patient’s status is indicated and the rehabilitation plans are modified accordingly. Principles of postoperative rehabilitation. The postoperative period can be divided into three phases: Immediate aftercare, rehabilitation and aftercare. Immediate aftercare begins with an evalu- ation by the therapist to determine the individual’s current physical capacity and to anticipate special needs. Pain management must be carefully ad- dressedaspreoperativepainisoftenthedrivingfac- tor leading to surgery and can impede the patient’s performance due to the physical and psychological implications. Treatment will include transfer and gait training, exercise instruction and education on basic back care. This will continue throughout the inpa- tient period or until independence is achieved. The rehabilitation phase continues until 6 months postoperatively. During this phase patients gradu- ally increase their activities of daily living, the home exercise program continues and all progresses under the guidance of the treating physician. Any inconsistencies between function and physical sta- tus must be addressed. During the aftercare phase, patients are expected to progress further in their functional level both personally and within the occu- pational and social spheres. Continued exercise is encouraged, both low back stretching and strength- ening as well as general aerobic conditioning. To date the existing scientific literature supports exercise after spinal surgery, although no particular form of exercise has been proven optimal. Little exists in the literature describing the ideal postop- erative rehabilitation protocol, and common clini- cal practice is the point of reference. All involved in spinal surgery rehabilitation must strive to fill these voids. Key Articles WHO (2001) International Classification of Functioning, Disability and Health. ICF, Geneva The International Classification of Functioning, Disability and Health was published by the World Health Organization. It describes situations with regard to human functioning and its restrictions from a biological, individual and social perspective. Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M (2003)Rehabil- itation following first-time lumbar disc surgery: a systematic review wi thin the frame- work of the Cochrane collaboration. Spine 28:209 –218 Systematic review of randomized controlled trials about rehabilitation following first- time lumbar disc surgery. No evidence exists for restriction of activity after lumbar sur- gery.Strongevidenceisfoundforintensiveexerciseprograms. Manniche C, Skall HF, Braendholt L, Christensen BH , Christophersen L, Ellegaard B, Heilbuth A, Ingerslev M, Jorgensen OE, Larsen E (1993) Clinical trial of postoperative dynamic back exercises after first lumbar discectomy. Spine 18:92 – 9 7 Randomized controlled trial investigating a high intensity compared to a mild physical rehabilitation program after discectomy. 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In case of a rehabilitation deficit, individual treatment and management is provided after 4 –6 weeks Treatment of a. physician and patient must have an unambiguous understanding of the other’s expec- tations and the role of each of them in the postop- erative recovery. After surgery, an ongoing reas- sessment of the