What is the role of physical therapy during the recovery phase of lumbosacral facet syndrome treatment?

Updated: Nov 19, 2018
  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD  more...
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Answer

Once the painful symptoms are controlled during the acute phase of treatment, stretching and strengthening exercises of the lumbar spine and associated muscles can be initiated.

Because Z-joint–mediated pain tends to be worse with extension, strengthening and conditioning exercises should typically be performed with a flexed trunk. Strengthening maneuvers must emphasize flexion, neutral postures, and pelvic tilt, all in an effort to reduce compression of the Z-joints.

Another therapeutic goal is to reduce the lumbar lordosis because excessive lordosis increases the loading on the posterior elements, including the Z-joints. Therefore, the patient should be taught pelvic tilt maneuvers to reduce the degree of lumbar lordosis. Pelvic tilt maneuvers can be taught in multiple positions (with knees bent while standing, legs straight while standing, and while sitting) to emphasize proper posture in multiple planes. Flexion-based exercises should be avoided in the presence of hypermobility or instability or if the maneuvers increase LBP.

Similarly, stretching exercises should be focused on restoring proper pelvic tilt; therefore, special emphasis should be placed on stretching those muscles that cause excessive anterior pelvic tilt (eg, the hip flexors and lumbar extensors). Stretching should be not limited to just these muscles because all the muscles attaching to the lumbar spine and pelvic girdle may be in imbalance, and regular stretching can help restore normal motion to the lumbar spine and pelvis. Therefore, stretching programs should also include stretches of the hamstrings, quadriceps, hip abductors, gluteals, and abdominals. Stretching through dynamic postural motions (eg, yoga postures) can be especially helpful because the motions can restore balance to the muscles of the lumbar spine and pelvic girdle.

These exercises are eventually incorporated into a more comprehensive rehabilitation program, which includes spine stabilization exercises. The goal with these exercises is to teach the patient how to find and maintain a neutral spine during everyday activities. The neutral spine position is specific to the individual and is determined by the pelvic and spine posture that places the least stress on the elements of the spine and supporting structures. Bridges and planks are ideal exercises for this as they can be done in the neutral spine position with high muscle activation and relatively low spinal loads. McGill recommends work up to 1 rep at 60 sec holds to build the necessary endurance for optimum spine function. [23]

Dynamic lumbar control is also incorporated to protect the spine from biomechanical stresses, including tension, compression, torsion, and shear. Spinal stabilization emphasizes synergistic activation of the trunk and spinal musculature in the midrange position by strengthening the abdominal and gluteal muscles and enables the patient to develop the muscles that support the trunk and spine and, ultimately, diminish the overall stress on the spine.

Not all patients have the same flexibility and strength imbalances. Individual, detailed assessment by an experienced physical therapist may allow for a tailored therapeutic program.


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