Spine

Core Framework: Pain, Positioning, and Performance

• The management of orthopedic spinal conditions is centered on three primary pillars: Pain, Positioning, and Performance. This framework is consistent with other orthopedic conditions but carries specific nuances for the back and spine.

• Pain Management

  • Application of cold is recommended early in the recovery process, particularly immediately following an injury or surgical incision.

  • The objective is to balance pain management with activity. Pain should be acknowledged, but it should not prevent the patient from becoming functional and mobile.

• Positioning and Precautions

  • Positioning is the most critical element for spinal recovery. Precautions are established to promote proper healing and protect the integrity of the spine.

• Performance and Equipment

  • Performance involves the use of adaptive equipment to maintain independence while adhering to safety protocols.

The "No BLT" Spinal Precautions

• The definitive mnemonic for spinal precautions is "No BLT," which stands for no Bending, no Lifting, and no Twisting. These movements are identified as poor body mechanics that cause strain and must be strictly avoided.

• Bending

  • Bending refers to the level-by-level curvature of the spine where each vertebra moves into a flexed position, creating a sweeping curve.

  • This is distinct from "leaning." In a lean, the individual maintains a straight, neutral spine and performs flexion at the hips. When movement is necessary, a lean is preferred over a bend.

  • Bending is particularly dangerous for patients with spinal fusions (e.g., $L3$ to $L5$). Hardware holds the fused vertebrae in alignment; if the patient attempts to bend, the strain is transferred entirely to the non-fused levels of the spine. This can lead to accelerated arthritis and the need for further surgery (e.g., expanding an $L3$-$L5$ fusion to an $L1$-$L5$ fusion).

• Lifting

  • Patients must never lift anything weighing more than $8\,lb$. For a practical mental image, $8\,lb$ is equivalent to the weight of a gallon of milk.

  • When lifting objects under the $8\,lb$ threshold, the object must be held as close to the body as possible. Holding a weight further away from the body increases the torque and strain on the lower back near the pelvis.

  • Proper lifting technique requires using the legs rather than the back to generate power.

• Twisting

  • Twisting occurs when the alignment of the shoulders changes relative to stationary hips. If the hips do not pivot along with the upper body, the spine must rotate to allow the change in direction.

  • This rotation puts significant strain on the lumbar region. In a post-surgical or arthritic spine, twisting can cause pain, disc degradation, and hardware complications.

Detailed Mechanics of Neutral Spine and Body Alignment

• The ultimate goal of positioning is to maintain a "Neutral Spine," which is an upright, tall, and straight posture.

• Natural Curvature

  • The spine is not a perfectly straight column; it has natural curves: lordosis in the cervical region, kyphosis in the thoracic region, and lordosis in the lumbar region.

  • While these curves exist, for the purpose of maintaining precautions, the spine should be treated as a single, solid column to prevent improper movement.

• The Golfer's Lift

  • This technique is used to retrieve small objects (like a golf ball or tee) from the floor while protecting the lower back.

  • Instead of bending both knees or curving the back, the individual kicks one leg out behind them while reaching down. This keeps the back in neutral alignment and limits lumbar strain.

• Standing Support at the Sink

  • During prolonged standing tasks, such as brushing teeth at a sink, low back strain can accumulate.

  • A specific strategy to alleviate this pressure is to prop one foot up slightly. For example, opening a cabinet door and resting a foot on the base inside the cabinet. Alternating feet can further distribute the load.

Functional Mobility and Bed Positioning

• The Log Roll

  • The log roll is the required method for transitioning in and out of bed to avoid twisting or bending the spine.

  • To exit the bed from a supine position: The patient rolls onto their side, moving the hips and shoulders simultaneously as one unit. Once on the side, they tip their legs off the bed while pushing up with their arms, maintaining alignment throughout.

  • To enter the bed: The process is reversed. The patient sits on the edge, tips over to the side while keeping the shoulders and hips facing the same direction, and then rolls onto their back as a single unit.

• Sleep Positioning

  • Pillows are used to reduce strain on the lumbar region by introducing slight hip flexion.

  • Supine: Placing a pillow or support wedge under the knees helps flatten the low back and reduce pain.

  • Side-lying: Placing a pillow between the legs allows the patient to enter a slight fetal position with the hips flexed, which is generally more comfortable for the back.

Activities of Daily Living (ADLs) and Equipment

• Standard orthopedic equipment used for spinal patients includes the reacher, shoehorn, sock aid, and dressing stick.

• Lower Body Dressing Challenges

  • Because patients cannot bend their back or flex their hips past a certain point, reaching the feet is difficult.

  • Supine Dressing: A unique approach for spinal patients is to perform lower body dressing while lying flat in bed. This keeps the back neutral while allowing the legs to be brought up.

  • Note: Supine dressing is typically contraindicated for hip and knee replacements because it may violate the $90^{\circ}$ hip flexion rule or strain the knees.

Spinal Bracing: The TLSO

• The most common brace encountered after spinal surgery is the TLSO (Thoracolumbar Sacral Orthosis).

• Structure and Function

  • The TLSO consists of a rigid back shell (the plate) and a chest element. This combination prevents the patient from entering a bending or twisting position by holding the trunk in neutral alignment.

• Doffing and Donning Protocol

  • The TLSO is typically worn at all times when the patient is out of bed.

  • The patient should log roll to the edge of the bed and don the brace before standing up.

• Skin Integrity

  • The brace should never be worn against bare skin. A shirt must be worn underneath the TLSO to prevent skin breakdown and maintain hygiene.

Energy Conservation and Compensatory Strategies

• Position Changes

  • Staying in one position for too long can increase back pain. It is recommended to change positions at least every $30\,\text{minutes}$. Some movement or a change in posture may actually relieve pain that has built up from static positioning.

• General Conservation Principles

  • Decrease the physical demand of tasks by sitting (e.g., sitting on a stool while brushing teeth).

  • Plan ahead and prioritize tasks to avoid clusters of heavy activity.

Questions & Discussion

• Question: A young adult client with a low back injury lives alone and must complete laundry tasks. To prevent re-injury, should the OT suggest placing the basket on the floor and sitting to fold, or dividing the laundry into small loads for carrying?

• Response: The client should divide the laundry into several small loads. Placing a basket on the floor is problematic because it requires bending and twisting to reach the items from a seated or standing position. Carrying small loads adheres to the $8\,lb$ weight limit to avoid strain.

• Question: A young adult with herniated discs at $L3$, $L4$, and $L5$ is learning lower body dressing. Is it better to teach them to lie flat and bend their legs up while keeping the back straight, or to use slip-on shoes as a compensatory strategy?

• Response: Lying flat (supine dressing) is the preferred technique because it is a specific spinal precaution strategy that maintains a neutral back while increasing independence. While slip-on shoes are a compensatory strategy, they only address footwear and do not help with pants or socks. Supine dressing is a comprehensive solution for lower body dressing in this population.

• Question: Why is it important to distinguish between "leaning" and "bending"?

• Response: Leaning involves hip flexion while the spine remains a rigid, neutral column. Bending involves the actual curvature of the spinal vertebrae. Since the goal is to protect the vertebrae—especially post-surgery—leaning is the only safe way to reach forward.