52 Lifestyle Medicine: Optimizing Recovery Following MIS of the Spine

Jaspal Ricky Singh and Kyle F. Worell

Summary

Lifestyle medicine is the use of evidence-based therapeutic approaches utilizing exercise, nutrition, and behavior science. In order to adequately address the burden of chronic disease and dysfunction, we must consider not only spine surgical treatments, but also preventative health measures to ensure optimal functional recovery. Through integrated exercise therapy, nutrition, health coaching, mindfulness, and sleep hygiene we have the potential to improve a patient’s quality of life, as well as achieve greater outcomes following minimally invasive spine surgery.

MISS allows earlier mobilization and initialization of a comprehensive perioperative rehabilitation program than traditional open surgery. This approach of combining the benefits of MISS with an earlier rehabilitation program of lifestyle modifications can amplify the outcome from spinal surgery beyond the benefits provided by the technical aspects of MISS alone (Table 52.1).

Table 52.1 Components of a comprehensive rehabilitation program

MIS of the spine has continued to evolve over the past several years and is now considered by many as the gold standard for spine surgery. With improved instrumentation and innovative buyout technological advances, the goal of MISS is to improve patient outcomes.¹ It has been estimated that approximately 60 to 80% of people will suffer from back pain at some point in their lives. The World Health Organization’s statistics find that lower back pain is one of the leading causes of disability in both developed and developing countries.² Given a continued increase in spine-related disorders requiring surgical intervention, it is likely that MISS will also evolve and grow accordingly. MIS procedures and techniques evolve with the aim of improving clinical outcomes. MIS seeks to reduce surgical complications, reduce postoperative pain, improve recovery times, reduce blood loss, shorten hospital stays, and reduce the need for pain medication. MIS allows for preservation of posterior motion segments and paraspinal musculature that allows for a quicker recovery and optimizes postsurgical functioning.^3,4,5

In this regard, MISS offers the great advantage over traditional spinal surgery of incorporating a comprehensive rehabilitation program much earlier and with potentially greater impact on patient recovery and health.

52.2 Exercise and Spine Therapy

Adequate amounts of exercise and physical activity promotes a healthy back (Fig. 52.1). Muscle makes up 40% of our body weight and healthy muscle is a key component for an active and pain free life. Conversely, as outlined in Chapter 5, there is an increased awareness that injured muscle itself can be a pain generator. Exercise and spine physical therapy are, therefore, critical during the postoperative phase. The purpose of physical therapy is to restore muscular conditioning and spinal structure in order to restore function and avoid reinjury.^6,7,8 Identifying the exercise objectives for each patient is critical to any spine program.⁹

For example, after a noncomplicated minimally invasive one-/two-level lumbar spinal fusion or decompression procedure we will progress rapidly with physical activity according to the following protocol:

•Start walking the same day.

•Upright bike, elliptical within 1 to 2 weeks after surgery, keep back straight.

•Pool exercises starting 2 weeks after surgery, when incision is healed.

•No bending, stretching, twisting for 6 weeks after surgery, abdominal quick draw binder optional and as per patient preference.

•Core exercise, stretching, and flexibility exercise starting 6 weeks after surgery.

52.2.1 Core Stability

One of the most fundamental concepts in the management of spine-related disorders, particularly cervical and lumbar pathologies, is the utilization and implementation of the upper back and core stability exercises. It is important to note that the terms “core” and “core stability” have been misused not only in the public in media, and but often among health care professionals also. The core and muscles involved in truncal stability are more than just “sixpack muscles.” Following MIS surgery of the spine, core strengthening exercises will vary depending on beginner, intermediate, or advanced levels. However, most central to the concept of core stability is facilitation and activation of the muscles involved with abdominal bracing (Fig. 52.2).

Abdominal bracing is an activity targeting the deep transverse abdominis muscle and the multifidi group contracting together with the surrounding abdominal and back muscles.8 This concept is known as “co-contraction.” The deep transverse abdominis is the muscle commonly called the “Corset of the Spine.” This muscle has been recognized as integral to the bracing process.

52.2.2 The McGill Spine Exercises

Just as each individual’s condition, diagnosis, and spinal dysfunction are unique, no two exercise programs will be the same. The following exercises have been chosen as general recommendations. These exercises are meant to serve as examples with the understanding that every individual and their specific needs vary. These exercises serve three main purposes: they spare the spine, they enhance the muscle challenge, and they ensure that spine stability is maintained.⁸

1.Cat-camel: The cat and camel, or spine flexion–extension cycle, is a motion exercise rather than a stretch (Fig. 52.3). These motions reduce spine viscosity (internal resistance and friction) and “floss” the nerve roots as they outlet at each lumbar level, followed by hip and knee mobility exercises. As the cat-camel is a motion and not a stretch, emphasis should be taken on motion rather than “pushing” at the ranges of flexion and extension. Five to eight cycles are sufficient to reduce most viscous-frictional stresses.

2.Bent knee curl-up: The bent knee curl-up is an effective exercise to target the six-pack muscles, also known as the rectus abdominis (Fig. 52.4). One can target these muscles by lying flat on the back while bending one leg up and keeping the foot flat on the floor. The other leg is left straight. Lifting the hands behind the head, raise the head and shoulders off the mat and contract the rectus abdominis muscles. Hold for 3 to 5 seconds. Slowly lower and repeat the exercise.

3.Bird-dog: The bird-dog exercise is critical in strengthening the lower back muscles. These include the lumbar paraspinal and the multifidus (Fig. 52.5). These muscles are often strained and weakened from sitting at work or at home for long periods of time. Begin by placing one’s hands and knees on a mat, keeping the elbows, wrists, and shoulders in alignment. Slowly string one leg behind the body. It is important to keep the pelvis level, as it is natural to rotate. A level pelvis will engage the multiphoton muscles. Hold this for 3 to 5 seconds and slowly lower it back to the mat.

4.Side plank: The side plank is the most advanced and difficult exercise that targets the deep abdominal muscles, particularly the obliques and the transverse abdominis muscle (Fig. 52.6). These muscles are very important for keeping one’s core stable and strong. To do this exercise, one must lie on the side, making sure that the elbow is aligned with the shoulder, and the knees are bent. Slowly straighten the top leg. Push off the elbow and knee, and raise the pelvis and hips off the ground. It’s very important to ensure that one’s bellybutton is pointed straight, as there is a tendency to either rotate upward or downward. However, make sure that the pelvis is level, and hold this for 10 to 30 seconds. Slowly release.

Another key benefit of MIS of the spine is the maintenance of spinal segmental stabilizers following surgery. In order to maximize segmental stability, the deep spinal extensor muscles are often spared during MIS and this can often lead to faster recovery.11

One of the major benefits of MISS is the reduction for potential spinal muscular injury to these structures.¹¹ The benefits for this include decreased muscular atrophy and a quicker return of neuromuscular facilitation. The targeting of specific muscular groups, namely the multifidi and the transverse abdominis, appear to be the focus in a large majority of spinal rehabilitation programs. Studies have shown the presence of atrophy in the multifidus group at the level of a known disc herniation. So while minimally invasive techniques may resolve the anatomic compression of nerves related to the disc herniation, surgical intervention on its own will not adequately resolve muscular weakness. Therefore, a graduated progressive exercise protocol for spinal stability should be emphasized.^12,13,14

Nutrition

Diet changes can be made to improve overall health and wellness, specifically spine health. Current recommendations reflect that a diet consisting of whole foods, with avoidance of inflammatory foods is the key to success and recovery.¹⁵ In addition, lean protein, an increase in key vitamins, and adequate hydration will promote tissue healing and bone health. It is important to note that following these diet recommendations helps to avoid chronic disease and pain as well as assists in recovery from MIS.¹⁵

Inflammation is the body’s response to any threat that challenges homeostasis. The body responds to this threat by releasing inflammatory chemicals.¹⁵ Assaults to the system such as lack of sleep, lack of or too much exercise, consumption of pro-inflammatory foods, illness, infection, or trauma eventually lead to a state of chronic inflammation (Table 52.2). Chronic inflammation can damage tissues without the presence of swelling, pain, redness, or warmth.¹⁵

Table 52.2 Pro-inflammatory foods

Research has now demonstrated that inflammation can also be triggered by psychological stress.¹⁶ Acute inflammation plays a positive role in the immune responses as it acts to repair and restore the body after infection.¹⁷ Inflammation is also a contributing factor to 8 out of the 10 leading causes of death in the United States.¹⁸ An increase in inflammation can also increase the risk of a major depressive episode by 21%.¹⁸ Chronic inflammation can lead to significant behavioral changes including depressed mood, anxiety, pain, disturbances in sleep, anhedonia, fatigue, irritability, social withdrawal, and psychomotor retardation.¹⁹

An anti-inflammatory diet reduces inflammation and moves the body toward a “deflamed” healthy state.¹⁵ The average American diet consists of 40% of calories coming from refined carbohydrates.¹⁵ These include refined sugars and refined grains. In total, a typical American diet consists of approximately 60% of calories derived from refined sugar, flour, and oils.¹⁵ Although these products may help make food taste good, they lack nutritional value and lead to “dietary injury” which causes inflammation, pain, chronic disease, suffering, and a slowed healing process.¹⁵ Foods made from these products also tend to trigger an addictive response in the body, creating an ongoing process.²⁰

Diets that focus on anti-inflammatory foods reduce pain, suffering, and aid those with chronic illness (Fig. 52.7). It is quite possible to eat an anti-inflammatory diet that allows one to lose weight, enjoy the food, and feel satisfied. One important concept that has gained more attention over the past few years is Glycemic Index (GI). GI is a value assigned to a food based on how it affects one’s blood sugar levels.²⁰ Foods with medium to high GI levels should be avoided as they tend to raise circulating glucose and insulin levels. Eventually, elevated circulating glucose and insulin levels lead to not only general pro-inflammation but metabolic syndrome.²⁰

Related posts:

IV MISS Techniques Mini-Open Pedicle Subtraction Osteotomy for Deformity Correction Cervical Three-Dimensional Navigation to Facilitate Minimally Invasive Spine Surgery Far-Lateral Lumbar Discectomies Posterior Cervical Facet Cages DTRAX MIS-TLIF with Total Navigation and Expandable Interbody Cages

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