Hi, my name’s Randy Bauer, and have been a physical therapist since 1987. I did my physical therapy training at Mayo Clinic in Rochester, Minnesota and prior to that I did my post-graduate exercise science training at Cal State Fresno and I did my undergraduate in health education where I was, uh, athletic trainer at Utah State University.
One of the main factors that I see when I have a patient that comes through my door and I’m going to initiate physical therapy is are they a candidate for surgery? And, often times, the doctor is going to refer that patient to me, hopefully, to skirt the issue of having surgery and those people come to me quite concerned. They come to me because they’ve been experiencing pain, some amount of disability for months, years, maybe decades and it’s... takes an impact on their life.
So, one of the first things I’m going to do is find out what’s important to them. Do they want to be able to play with their grandkids? Do they want to be able to travel into their retirement years? Or, do they want to go out and play golf three days a week? Or, do they want to resume a high-level sport? I have to listen to them to tailor each program effectively for them to get back to those activities.
If I was to look at some of the major habits that influence back problems, I would go to sleep habits. You need sleep. Sleep is where our body recovers. You have to be able to assume a good position to sleep. Very important for me to spend some time on my patient education on sleep habits and whether it’s the mattress that they’re sleeping on or the position that they sleep. The other issue I see is nutritional habits and nutritional habits plays a major role because it dictates the nutrients that our body uses to help with injury, to recover from injury.
You also have problems related to carrying too much weight. You can’t carry around 10 extra pounds to fatigue your muscles, to irritate the joints and create pain and then get up and go on your journey the next day. So, diet is important. Fitness is huge. For the body to adequately provide oxygenated blood to the muscles and to the tissues, we need to be able to have some level of fitness.
Next, I would say it’s maintaining a neutral spine. It’s maintaining a chest-out positioning to where the muscles around the shoulders and neck don’t have to exert themselves. It’s having some adequate mobility in the hips. But, as soon as you see hips not being able to move and the mid-back becoming stiff, then what happens is all that stress is exerted down to the lumbar spine in that twisting movement.
As a physical therapist, in looking at some of the habits that I’m going to be improving in my patients, I need to look at not just the lumbar spine, I need to look at the big picture of what joints are moving or not moving, what their postures are, what their work habits are, what their lifestyle habits are and also what type of activities do they want to be engaging in in the long term. And, that’s where the importance of core muscles come into play.
Some of those muscles dictate very small rotational movements and create stability of isolated segments in the spine. In the lumbar spine those muscles create a little bit of rotation. They might create a little bit of side bend, they might prevent a little bit of sheer force. And then, you have your larger core muscles that are going to create more power and more strength exertion. So, if you emphasize just the big muscles of the core, you’re missing out on some of the finite stability that takes place at the local segments of the spine.
Lumbar microdiscectomy is performed after a herniated disc and there’s some pressure being exerted on the spinal cord and/or the spinal nerve route. And, often times, with those procedures, you’re dealing with some residual leg symptoms. If you’re able to come into surgery and you’re having less symptoms, we are often able to progress you a little bit faster through that rehab process. We’re not having to deal with reducing leg pain; we’re not having to reduce strength in the specific muscles. So, when we’re looking at a post-discectomy, one of the major things that we’re trying to protect is the healing of the disc.
I can remember a situation where a patient of mine came in and was two months after post-lumbar discectomy and he was an avid golfer. And, I told him he’s not gonna be golfing at least for six months and he was feeling good. He had reduction of leg symptoms post-operatively, he had some mild back pain that was managed with therapy and he was progressing well on his strengthening. He started to goad me a bit on can he start golf early. I said no, don’t start golf early and he did. He went back and he golfed and he re-ruptured the disc and developed foot drop and that foot drop persisted.
I can treat somebody and get them better after a surgery without needing a lot of back movement. I want my patients’ hips to move. I want my patients’ legs to get stronger. I want their back mechanics to be solid. They need to be able to roll up and out of bed. They need to be able to relieve the postural stress that they experience any time through the day. They need to be able to get their exertion level back to where they’re walking on a regular basis.
So, when I have a patient that is coming in after a spinal fusion, that patient may not see me for three to six months sometimes after surgery. When they’re coming out of that stabilization protective mode, they may have been wearing a brace for some time. That brace is gonna cause some weakening of the back. That brace is gonna cause some stiffness in the leg muscles and other muscles in the body.
We’re gonna be managing pain and a slow introduction into exercises that are tolerated by each individual. Second phase is going to be introducing an increased level of exercise. It’s going to be showing a higher level of function from doing basic activities in the house to maybe doing some very light activities, very light lifting, less than 10 pounds and performing a routine that they can manage on their own.
Our final stages of post-operative rehab are going to introduce the activities that are consistent with that patient’s goals. So, it’s important for me to have an open line of communication with the patient, okay, so that I know that what I’m instructing them is consistent with their healing process.
Well, one of the biggest components that I see that gets in the way of healing the spine and restoring your normal activity is some of the chronicity that takes place with a back problem. You have certain limitations you start placing on yourself. You have family issues that come about. All that starts playing a major role in a patient’s mindset. And so, it’s important for me to spend some time trying to improve that mindset, okay. I can tell people that I take care of peoples’ bodies from their neck to their toes and I don’t have anything to do with what’s between the ears.
And, sometimes all you need to do is say, “we just need to succeed with one thing,” okay. And, that one thing might be what do you do when you get out of bed in the morning that can help your back? And, those small successes then become a new activity because one of the biggest things that works against that positive mindset is yourself. I can’t do this. If I do that, it’s gonna cause this problem. If I can’t do that, what’s my wife gonna think? If I can’t get back to work in time, am I gonna have a job waiting for me? Okay. So, it’s very important to take a step back and look at what small successes can you start building and from there start moving forward and building on those small successes.
Our social relationships are very important. And, with back pain, that can get in the way of our social relationships. It’s one thing to have a relationship that’s not going well at work, but when it is with our loved one, and I mean a wife or husband, and that includes sexual relationships, that can become a big problem. When we’re dealing with returning to sexual relationships after surgery, or even with a chronic back issue, there has to be exploration that comes into play. No pun intended. You need to be able to try different positions. You need to think about positions that you would normally sit, stand, lie down and how those positions normally would feel with your back.
And, it might start off that you spend time with your loved one and try those positions with your clothes on and anywhere in the house is okay. Okay, you need to find and make fun of it. You need to laugh a little bit. Wherever you might find yourself, there is a huge area for developing and maximizing your intimacy level.
Patients have expectations coming out of the surgery. One patient’s expectation might be that they’re going to get back and play golf three days a week. That may not be a realistic expectation. You have to set the goals low to begin with and realize success. And, once you start realizing success at a lower level, you can start building to an intermediate level. So, they’re not overshooting what they’re expectations are and if I can get somebody to do more than I initially said that they were going to be able to accomplish, that is a success because then the patient starts to see that they had a major role in that.
As a physical therapist of 27 plus years, the most gratifying part of my profession is to be able to have somebody walk in in one condition and walk out in an improved condition. It’s being able to have the guy come in and telling me he’s, you know, a six handicap now and he was a 12 handicap. It’s the fellow that just lost 30 pounds, okay, and he might be taken off of his statin drugs because he’s losing his weight. It’s having some influence over the patients that come to see me and their health.