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SPINAL FUSION AND
REHABILITATION AFTERCARE
MOHIT K. BHATNAGAR, MD, MP, JOHN P. KOSTUIK, M
S. MICHAEL T. TOOKE, MD, CAMERON HUCKELL, MD
Rehabilitation plays a vital role in patient recovery following spine and extremity surgery. Recent advances in
instrumentation and techniques of fusion have altered the approach to postoperative care. Progression from restricted bedrest, unwieldy casts, and cumbersome orthotics to functional bracing and, often. no immobilization
has been possible with the use of improved motion segment fixation. Furthermore, the significant morbidity and weakness associated with bedrest and immobilization have been minimized, and earlier recuperation has
resulted from accelerated physical medicine and rehabilitation programs.
This chapter provides guidelines for the rehabilitation of patients who have undergone spinal fusion. Instability requiring fusion of the
cervical, thoracic, and lumbar spine may result from a variety of degenerative, infectious, neoplastic, and traumatic etiologies. The purpose of spinal fusion is to prevent further neurologic deterioration and to
maximize function by diminishing abnormal motion, preventing progression of deformity, and minimizing pain (Table 1). The postoperative rehabilitation of patients undergoing spinal fusion depends on numerous factors.
including age of the patient, extent of the spinal disease, association and degree of neurologic involvement, duration of symptoms, overall debilitation of the patient, associated medical ailments. and social backaround
and psychological constitution of the patient. 42, 99
The primary goals of a postoperative rehabilitation program are to maximize function, decrease pain, strengthen weak muscles, stretch contracted
muscles, decrease mechanical stress to adjacent structures, stabilize hypf rmobile segments, improve posture, improve fitness to prevent injury, improve mobility, educate patients, suggest environmental alterations, and
develop a preventive maintenance program (Table 2).43,10-75
Psychological well-being also must be considered. The majority of patients undergoing spinal fusion for degenerative conditions should have been involved in a preoperative rehabilitation program. This preoperative program should be titrated to the patient's tolerance to specific exercises formats (i.e., stretching, strengthening, and aerobics). Additionally, the preoperative program should include conceptual teaching of pathology, factors related to pain perception and modulation, and functional and exercise formats (i.e., Back School),
70-75
TABLE 1 Spinal Fusion: Goals
Prevent neurologic deterioration Maximize function
Decrease pain Prevent progression of deformity
Diminish abnormal motion
POSTOPERATIVE REHABILITATION PROGRAM
The postoperative rehabilitation program can be divided into three phases: (1) postoperative hospital phase; (2) early postoperative
posthospital phase; and (3) later postoperative posthospital phase.
Phase 1 (Fig. 1) corresponds to the
first 5-10 days following surgery. The postoperative phase includes brace fitting and modification, bed mobility and transfer training, and balance and gait training. The program should begin at an appropriate level and
progress according to gains in range of motion, flexibility, strength, and pain reduction. The functional goals of the hospital period are independence in activities of daily living, which include the ability to
ambulate on stairs and/or flat surfaces for set distances (often 200 feet) as well as the ability to eat, drink, and take care of personal hygiene. With changes in health care and forces mandating early discharge, this
often requires further inpatient rehabilitation at physical medicine and rehabilitation facilities or home help in the form of aides and home physical therapy.
Phase 2, the early postoperative posthospital phase,
concentrates on aerobic conditioning and the use of modalities to help with pain control. We recommend progressive ambulation for the first 6 weeks postoperatively as the safest and easiest means of developing stamina.
Patients are encouraged to ambulate as much as possible, but to ambulate 2-3 times per day for shorter distances rather than once for longer distances. The exercise period includes brisk walking for prolonged intervals
of time and distance with warm-up and cool-down periods of 5 minutes before and after the session. By the end of 6 weeks, patients should be walking 1 mile or walking briskly for 20 minutes 2-3 times a day.
After
the 6-week follow-up, the patient is usually advanced to other low-impact aerobic activities. Stairmaster, upper body ergometer, stationary bicycling, and swimming are advocated as adjuncts to walking. Swimming provides
many advantages, including buoyancy to minimize compressive axial forces, and resistance to muscular forces. Pool walking and floating may be needed prior to actual swimming in deconditioned or debilitated patients. The
majority of swimming strokes promote truncal extension; the sidestroke minimizes extension and rotation, whereas the breaststroke minimizes rotation while creating greater extension forces in the cervical and lumbar
spine.61,64 Rotational and flexion/extension exercises and movements are still restricted to protect the fusion during this phase.
Progression into phase 3, usually at 3 months, includes the
introduction of new stretching and strengthening programs. Active and passive stretching with proprioceptive neuromuscular facilitation modalities are advocated for the trunk and extremities. Extremity strengthening
with a full progressive resistive exercise program using isotonic, isometric, and isokinetic techniques are efficacious, and trunk isotonic and isokinetic exercises appear to work best in our experience. Complex and
stressful techniques, including ski machines, Versa climber, and eccentric formats as well as higher impact aerobic modalities (treadmill, jogging), have been recommended by some for the end of the rehabilitation
program. Cavanaugh10 has shown that running activities cause more than 2,000 N of force (2.5-3 times body weight) at heel strike. Significant loads are transmitted to the spine,16
and disk height decreases by an average of 3.2 mm. after a 6-kin run and 8 mm. after a 19-krn run.85
We do not advocate running, jogging, or similar percussive techniques at any phase after lumbar spinal fusion. The risks and benefits of recreational resistive and contact sports should be weighed carefully. Pain-free axial range of motion, extremity and trunk strength and flexibility, and overall aerobic capacity must be taken into consideration before allowing for safe participation.
ORTHOTIC DEVICES
The choice of external immobilization depends on biomechanical and physiologic factors. The choice of orthosis depends on the length of fusion, type of fixation, quality of bone stock,
amount and type of bone graft, the patient's healing potential (nutrition, smoking), and other factors.82
The final decision should be made by the surgeon; instrumentation that provides maximal internal rigidity requires rninimum Pxternal support.
White and Panjabi 100
have helped to define much of our knowledge concerning normal spine motion and biomechanics. They group orthotic devices according to the extent of control over segmental and coupled motions and classify orthotics as having minimal, intermediate, or maximal effect (Table 3).
In the cervical spine, minimal control is achieved with soft collars, but they provide warmth and proprioceptive feedback and are inexpensive and convenient. Intermediate control is provided with Philadelphia
collars in flexion and extension, but less so in axial rotation. Greater limitation in all planes is obtained with long 2-poster and 4-poster braces.41,47
Cervicothoracic orthoses, such as the sternal occipital mandibular immobilizer (SOMI), is effective in minimizing upper cervical motion (C 1-5) in flexion, but is less effective than a 4-poster or molded cervicothoracic orthosis (Yale brace) in controlling rotation and lateral bending.
24 The Yale brace is the most restricting of the nonhalo orthoses but limit lateral bending only by 50%.46,47
Maximal control of the cervical spine is obtained with the Minerva jacket and halo apparatus with limitation of greater than 95% of motion in all planes (Table 4).85
However, paradoxical snaking can occur in the lower segments of the spine (below C3-4), and loss of reduction and increased motion up to 70% of normal with activities of daily living have been reported.46,47,5l
Posterior plating of the cervical spine has been shown to be superior to posterior wiring techniques by providing stability in all planes. Wiring sustains only tensile loads and allows greater rotation and translation and requires additional external immobilization.
26,68
0ur philosophy is to provide maximal internal support, using both anterior and posterior instrumentation if needed, and then utilizing a cervicothoracic orthosis (Miami-J collar or collar-vest). We prefer not to use the halo vest or Minerva cast unless absolutely necessary because of complications, such as pin problems, pain, infections, and patient acceptance and compliance.
In the thoracic spine, newer instrumentation systems, including the CotrelDubousset and other rod-hook systems (e.g., Universal, TSRH, Moss-Miami), provide significant internal stability, often mitigating the
need for external support. When minimal support is needed, a long corset will suffice. But for intermediate control, a three-point fixation system, such as the Taylor, Jewett, and cruciform anterior spinal
hyperextension (CASH) orthoses, should be used to limit flexion and extension (see Tables). Maximal control is obtained with a Risser cast or Milwaukee brace, which can control motion in rotation as well as flexion and
extension by the use of pads, straps, and pelvic molding. However, when Harrington rods are used or the spine is very osteopenic or kyphotic, we prefer the thoracolumbosacral ortbosis (TLSO) or body cast. 13,23
In the lumbar spine, lumbar pedicle fixation provides maximal stability in all planes, including axial rotation, and requires minimal external support.82
Additional anterior instrumentation doubles the stiffness of the system and requires less external support.' Lumbar spine corsets with metallic stays or molded structures provide minimal control of motion but do help psychologically or with proprioceptive feedback. Knight or chair-back orthoses provide intermediate control, limiting all motion except rotation. Maximal control is provided by molded TLSOs with a thigh extension or a halo-pelvic apparatus. Limitation of axial rotation is provided with incorporation of the hip, and the upper lumbar spine is restricted by 80% in extension and 50% in lateral bending by adding the thoracic levels.
54,55 Rigid custom orthoses limit gross motion better than off-the-shelf orthoses,22,37 but data are conflicting with regard to intradiskal pressure,52,70-75 muscle activity,
54,55,70-75 and intersegmental motion.59,79
Lumbar orthoses do not decrease or substitute for muscle activity, and studies have reported a 33 % increase in paraspinal muscle myoelectric activity with orthosis usage. Lumsden and Norton 59,79
separately reported increased intersegmental motion with some restriction of gross motion with orthoses. Furthermore, orthoses, which do not incorporate the hip, can lead to greater stresses at lower lumbar levels, thereby increasing the stress on the fusion and instr-umentation. Fidler and Plasmans
12 demonstrated that lumbosacral motion was reduced by only 30% without a thigh extension, but the addition of a thigh extension decreased flexion and extension by more than 90% at the L4-5 and L5-S1 levels.
The use of orthoses has been and will he an integral aspect of spine surgery, but the costs and risks [benefits of external vs. internal stabilization have to be weighed carefully and assessed on an individual
basis. If adequate internal stability is achieved, then minimal or no bracing will allow for faster recuperation. However, if the internal fixation is poor or the risks of motion are high (in terms of neurologic status
and fusion), the use of a rigid, custom-made orthosis will be necessary.
ADJUNCT PAIN REDUCTION MODALITIES DURING REHABILITATION
The use of modalities as an adjunct to a well-designed restoration
program can enhance recovery. The combination of modalities used must be individualized depending on the source of pain and intended result. The various modalities include heating devices, cryotherapy, phonophoresis,
electrical muscular stimulation, and transcutaneous electrical nerve stimulation (TENS). None needs to be used long-term.
Heating modalities can increase the extensibility of collagen tissue, decrease joint
stiffness, provide pain relief, relieve muscle spasm, and increase blood flow to assist in the removal of noxious substances. 56,51
The choice of heating modalities depends on the localization of the discomfort and the desired anatomic level of heating. Superficial heating modalities include infrared light, hot packs, and heated air and hydrotherapy. Deeper heating techniques include shortwave microwave modalities for muscle and ultrasound for joints, myofascial interface, tendon, and nerve sheaths. To adequately treat stiff joints, tendons, and muscles, stretching programs under proper supervision must be implemented in conjunction with deep heating modalities.
All superficial heating devices can be used safely in patients who have had spinal fusion, but the deep heating modalities should be used with caution in patients who have undergone a laminectomy and fusion.
Care must be taken to avoid skin burns in areas desensitized by incisions. Directing the ultrasound beam away from the uncovered dura and toward the facet joints and paraspinal musculature will eliminate the likelihood
of dural heating.17 Increased temperature rise does not occur in areas of metallic implants; thus, ultrasound can be used in areas of spinal instrumentation.28
Pain reduction may be accomplished using superficial heating modalities.
Cooling modalities (cryotherapy) may be used clinically to reduce muscle spasm and spasticity, to decrease bleeding and edema, and to
reduce pain and inflammation. Blood flow is decreased and joint stiffness is increased with cooling modalities. Additional resistance to stretch may help to provide initial stability and pain relief by minimizing
myofascial extensibility and irritability caused by overstretching of the soft tissues.56,57Phonophoresis, the introduction of hydrocortisone into the deep tissues using ultrasound, has been
reported to have beneficial effects in reducing inflammation.38 However, more recent clinical trials found no statistical difference between ultrasound with and without hydrocortisone.67
These seemingly contradictory results may be due to the fact that specific anatomic delivery and dosage cannot be controlled and, therefore, may not provide the intended desirable effect over ultrasound alone. We do not prescribe phonophoresis.
Electrical muscular stimulation may result in a significant decrease in pain by increasing blood flow and interfering with the creation of spasm. It also initiates contraction of the stimulated muscle and can
increase muscular strength96
and joint proprioception. TENS has been widely used in postoperative pain management. The mechanism of pain reduction may occur via the modified spinal gate theory or via an increase in endorphine.30
This is used in about 10% of our patients.
TRUNK MUSCLE STRENGTH AND ENDURANCE
The dual functions of the trunk muscles are to maintain the stability of the vertebral column and to control
intervertebral spinal motion. The activities of different trunk muscles cannot be isolated or measured directly in mechanical quantities; they can be estimated only indirectly by means of electromyography, intramuscular
pressure, and muscle strength.5
Unfortunately, all these studies have been done for acute and chronic low back pain. It is unclear whether they are applicable, and in which way, to the problems of spine fusion. However, spine fusion is generally performed for chronic low back pain; the data regrading muscular strength and endurance, or aerobic capacity, are probably valid. The techniques of spinal fusion usually contribute to the degeneration of the paraspinal muscles in the area of the fusion. A successful fusion will also render these small muscles functionless in the vicinity of the fused segments.
Although the scientific methodologic problems are associated with each of the tools to measure trunk muscle strength, it is generally agreed that men as a group are stronger than women, but when strength is
normalized to body weight, women may be as strong as men .49,74,93 The eccentric (lengthening) dynamic and isometric contractions produce higher levels of strength than concentric (shortening) contractions
. 49 As expected, the trunk extensors are stronger than the flexors, with the trunk extensors actually being the strongest muscle group in the body. In studies by Smidt and associates, 93-95
the average moment of force generated for eccentric extensor muscle contractions was in excess of 400 Nm. Furthermore, they found that the trunk extensor strength in postmenopausal women is more than double the strength of the knee extensors. Of interest, trunk strength seems to diminish noticeably with age, beginning at 40-50 years,
97 but the endurance of trunk muscles in women is superior to that in men.93-95
Comparisons of patients with low back pain with normal subjects using peakstrength measures for isometric and
concentric contractions do not demonstrate significant differences between the two groups. 49,78,93 Nachemson and Lindh 74
found differences in the strength of trunk muscles only in relation to the duration of back pain. They found that patients who are inactive for more than a month because of pain demonstrated muscular weakness in both trunk extension and flexion. Investigators have also found a positive relationship between degree of disability and loss of the flexion-relaxation phenomenon. Differences in the expected relaxation of the back muscles during complete flexion of the trunk, the flexion-relaxation phenomena, have been noted on myoelectric measurements of normal subjects as compared with patients with back pain.
26,31,92
Other longitudinal studies show a greater frequency of low back pain in patients with poor abdominal muscle function.50,87
Not only is the strength of trunk muscles thought to be weaker, but also the endurance of the back is suspected to be diminished. Early detection and precise evaluation of back muscle fatigue are of practical importance. It has been theorized that the structures constituting the functional spinal unit are increasingly subject to mechanical stresses when muscular support is inadequate.
92 Recent evidence has shown that deficiencies in the lumbar musculature are often associated with chronic low back pain.88,89
This assertion is also supported by the high incidence of back injuries in workers exposed to wholebody vibration or repeated heavy manual tasks, both of which are associated with myoelectric evidence of fatigue.
11,48
Fatigue, as defined in mechanical terms, is the point at which a contraction can no longer be maintained at a certain level (isometric fatigue) or when repetitive work can no longer be sustained at a
certain output (dynamic fatigue).5
Abnormalities in strength or endurance of paraspinal muscles may act independently as sources of pain. Over time, back pain causes decreased muscle strength. In addition, the lack of muscle endurance may add to the perpetuation of back pain.
60,84
In both cases, the mechanical events are preceded by biomechanical and physiologic events within the muscle, not measurable in mechanical performance. Unfortunately, no pathologic or biochemical studies specific to the back following fusion have been done.
Mechanical tests of trunk muscle endurance have included maintaining a posture, and performing an activity repeatedly. 7,40,48,76,77,93-95
These studies of isometric endurance found that patients with low back pain had significantly shorter endurance than controls, but there were no differences in isometric back muscle strength between patients and controls. Jorgensen and Nicolaisen
48
tentatively suggested that the possible difference was due to the fact that fiber composition in the two groups was different; the composition of back muscles in the patients was dominated by a greater proportion of easily fatigable, smaller type 2 fibers. They speculated that, as a consequence, such individuals ar exposed to postural stress and impaired coordination of the postural muscles, which may predispose to injury.
Surface electromyography (EMG) has been the other major technique used to study the fatigue properties of back muscles. The major technical advance has been detection of electromyographic signals with power
spectrum analysis for the quantification of localized muscle fatigue. Okada, Andersson, and Jayasinghe 4,1,46,83
discovered that the electromyographic signal increased initially with fatigue but decreased persistently in the contraction's later stages. They also observed that the low-frequency components of the electromyographic power spectrum increased consistently throughout the contraction. Both patients and controls exhibited a trend toward increasing fatigue rates with increasing force; however, higher fatigue rates were observed in patients than in controls. Roy and associates reported that such changes in the median frequency of the electromyographic signal are related to the accumulation of metabolites in the muscle fibers and provide a biochemically related index of muscle fatigue during sustained contractions.
88,89 They concluded that muscle weakness or fatigue is associated with low back pain.
MUSCLE STRETCHING
The use of a systematic stretching program can reduce pain in patients after spinal
fusion.99
The stretching of joints and associated paraspinal muscles adjacent to the fusion should have the desirable effects of reducing contracture and restoring motion and increasing cartilaginous lubrication and nutrition by increasing synovial fluid production.
61 Resolution of lumbar spine pain has been reported with a well-designed stretching program.51,86
Although adequate mobility of the spine is necessary for normal function, the total range that has the greatest mechanical efficiency, that is best for tissue nutrition for disks and cartilage, and that maintains adequate facet motion has not been determined. Too little motion (< 30
0) may limit flexibility, whereas too much can excessively load the spine. Exercises that attempt to increase spinal mobility beyond the normal ranges of motion are not necessarily beneficial.21
Stretching can be achieved in a variety of ways, including active and passive positioning, mobilization, manipulation, proprioceptive neuromuscular facilitation (contract-relaxation methods), and muscle energy
techniques.99
A stretching program for the neck and trunk increases soft tissue extensibility, reduces muscular spasm, and restores functional muscular length. Flexibility of the upper and lower extremities allows for greater leg motion without compensatory spinal motion and provides greater absorption of forces directed toward the spine.
32-35 Mellin65 showed a correlation between greater hip mobility and lumbar spine mobility with less back pain.
Manipulation of the spine after fusion is not advisable, but limited soft
tissue and joint mobilization and muscle energy techniques can be used to free and stabilize restricted motion segments above and below the fusion.99
These techniques provide a concentric or eccentric isotonic or isometric contraction that is applied in a controlled counterforce.99
Functional patterns of motion can be established within the physiologic pain-free range and slowly extended into more restricted and previously painful arcs of motion. Because the magnitude of force is low and specific, mobilization and muscle energy techniques can be safely used after the fusion has matured, but they should be performed by physicians and therapists who are experienced in their use. These techniques should only be used later in phase 3 of rehabilitation.
MECHANICAL STRESS AND POSTURAL CONTROL
The role of mechanical stress in low back pain has been substantiated, and both flexion and extension exercises have been advocated as beneficial in reducing
mechanical stress and facilitating the spine's ability to withstand axial compression. 32-35,70-75,90,91 Varlotta and Errico99
believe that "dynamic muscular fusion" can be obtained in the cervical and lumbar spine through synergistic activity and coactivation of anterior and posterior musculature. They believe that dynamic internal muscular stabilization can protect the fusion and adjacent segments from single overload and repetitive microtrauma.
In the lumbar spine, an increase in intraabdominal pressure has been reported to have a stabilizing effect.70-75
Proponents of abdominal strengthening exercises cite these studies and their role in reducing loads on lumbar disks and advocate flexion exercises.15
Conversely, proponents of extension exercises cite investigations of disk pressure measurements to dispute the value of isotonic flexion exercises and advocate maintenance of normal lumbar lordosis to withstand axial compression to the spine.
70-75 In electromyographic studies, an increase in intraabdorninal pressure lessened the load on the spine by balancing the forward bending moments with erector spinae activity.6,41,69 It appears
that synergistic muscular coactivation of all trunk muscles is needed to assist in maintaining a neutral spinal alignment, axial stability, and reduction of segmental shear forces.32-35,90
Postural
dysfunction is recognized by both the public and professional communities as a cause of chronic low back pain.63
The paraspinal muscles are involved not only in job-related tasks but also in the maintenance of posture. De Vries 18-20
demonstrated EMG abnormalities of paraspinal muscles, suggesting muscular deficiency as a cause of poor posture. A review of the literature shows that various physical exercises, either alone or in conjunction with postural training, have been attempted as treatment regimens. The most popular are flexion exercises designed to increase abdominal muscle strength, thereby reducing lumbar lordosis. Unfortunately, exercises to improve structural postural abnormalities or directed at stabilizing a hyper- or hypomobile segment are not effective.
14,27,43
Paraspinal muscles lack the voluntary control to allow for specific segment strengthening, and the degree of structural lordosis is unrelated to abdominal or back extensor muscle strength or to hip and trunk flexibility.
25
EDUCATION AND ENVIRONMENTAL ALTERATIONS
Research into the role of intradiskal pressure has repeatedly shown that specific human motions, including selected physical exercises,
significantly increase the stress to the lumbar spine.3,470-75
As a result, many researchers propose that such motions be avoided, and, in fact, this research evidence is the basis for the body mechanics education and "back schools" popularized as biornechanical alternative treatments for low back pain. We routinely teach patients proper techniques for such activities as standing, lifting, sleeping, sitting, and to minimize stresses on the back. Furthermore, therapists evaluate and recommend ergonomic alterations to job sites and homes to help prevent and reduce possible problems.
GENERAL CONDITIONING
Although the beneficial effect of exercise in patients with spine disorders has been established, no studies have specifically evaluated the effect of exercise in fused patients.
Exercise or general conditioning is important in the maintenance of spinal structures. Bone mineral density has been found to be greater in patients who are involved in a variety of sports activities than in those who
are more sedentary.36,44,53 Nutter80
believes that endorphins and improved circulation are beneficial effects of exercise in all patients with spinal disorders. Aerobic exercise in rheumatoid and osteoarthritic patients has resulted in improved aerobic capacity and a reduction in morning stiffness, pain and swelling.
39,66 Additionally, endurance exercises increase tensile strength of tendons and ligament-bone interface and reduce the stresses placed on adjacent structures.98
Physical exercise has demonstrated effectiveness in improving general attitude12 and in relieving depression.65
Good general fitness is associated with decreased incidence of back injuries and decreased duration of incapacity with a back injury.9 Furthermore, exercise is known to reduce stress, 18,19,20
to facilitate sleep,8 and to reduce muscular tension. 18-20, We believe that following spinal fusion, patients can return to most sports, although body contact sports should be avoided.
CONCLUSIONS
Little information exists regarding the specific value of physical exercise in the treatment and management of spinal fusion. The pathology, anatomy, and physiology of the trunk muscles following
surgery and possible denervation are not known. Similarly the factors and events leading to fusion are poorly understood (i.e., what effects do cyclic loading have on the fusion, how much loading is helpful, and what
motions and stresses are harmful?). Many beliefs commonly held in clinical practice lack research verification and continue to be taught and used on the basis of empirical findings, lack of effective alternatives, or
both. However, some principles learned from chronic low back pain patients can be extrapolated to these patients.
Evidence substantiates the prevention of back injuries as well as decreased intensity and duration
of pain through the use of conditioning exercises. Support has also been found for decreased duration of impairment and prevention of chronicity, and adequate trunk muscular strength appears mandatory for a return to
function and employment follow back injury and pain. Finally, data substantiate the role of physical exercise in the general restorative treatment of patients with low back pain, especially those who suffer associated
depression, stress, insomnia, and chronic muscular tension. We believe that a graded aerobic conditioning program is essential in the recuperation of patients following spinal fusion. Other modalities have not been
proven to be as effective and await further trials to determine their efficacy.
Ideally, we will develop a methodology for evaluating and treating low back pain as well as managing the rehabilitation of patients.
This goal will entail (1) electromyographic testing of the subject pre- and postoperatively to determine muscular imbalances and deficits, (2) analysis of the muscle forces in the trunk and lower back using a
biornechanical model, and (3) developing an exercise prescription to remedy the lumbar muscle insufficiency by starting at an appropriate level that is individualized to the patient and titrated according to clinical
and biornechanical response.
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