THREE-MONTH TIMETABLE FOR HEALING
Weeks 1 to 4
Aggressive rest phase, corset first goes on.
Floor exercises: comfortably, easy, 3x per day.
Medication: Prednisone four to seven days x2 refills.
Aleve 440 mg b.i.d. or ibuprofen 400 mg t.i.d., Soma, Flexeril, temazepam at bedtime p.r.n., opioids at bedtime only for three to seven days p.r.n. and at bedtime only when ambulation begins.
Begin a walking program 10 to 30 minutes one to two times per day with corset. Sitting and standing precautions.
Lumbar steroid epidural injection, p.r.n. severe sciatica with minimal help from oral prednisone.
Weeks 5 to 8
(Mobilization, phase 2)
At weeks 5 to 8, the patient is frequently back to work on a regular basis, or at least part-time, emphasizing sitting precautions and mobilization. The patient continues to wear the corset 100% of the time but by six weeks begins to reduce the corset use if tolerable. Otherwise the corset is continued for a full 8 to 12 weeks.
Floor exercises: two times per day, five repetitions, holding 10 to 20 seconds.
Medication: Naprosyn or ibuprofen at bedtime only. Occasional prednisone four to seven days p.r.n. Occasional Soma, temazepam. No opioids.
Walking 30 to 60 minutes daily with a brace. Sitting and standing precautions.
Lumbar steroid epidural if repeat oral steroid does not relieve symptoms.
Weeks 9 to 12
(Activities and strengthening, phase 3)
At this point the patient is pretty much doing all activities of daily living much of the time without the brace, sometimes with the brace but taking no pain medications during the day and doing most activities. At this time it is frequently about how to get back to more aggressive activities and more normal heavy lifting and carrying.
Once corset continues to be worn 60% to 100% of the time and once patient is able to walk 60 minutes with a corset and then gradually increasing walking without the corset, the patient could work half time without the corset. They should continue the corset for risky back tasks for months.
Floor exercises: 2x per day five reps holding 10 to 20 seconds.
Naprosyn or ibuprofen at bedtime only. Rarely Soma or temazepam at bedtime only.
Walking 30 to 60 minutes daily with or without the corset. Sitting and standing precautions.
Begin yoga, bike, swimming. Add gym or Pilates cautiously with a corset. Golf and tennis are added. If it is okay to walk 60 minutes without the brace then it is okay to play without the corset.
Bed rest is the mainstay in the early treatment of severe painful degenerative disc disease and lumbosacral sciatica. When being vertical and sitting is too painful, patients must remain lying down until they are able to mobilize more than 5 to 10 minutes every hour. At this point, patients with their corset on and a dose of prednisone should be getting up and mobilizing, walking 5 minutes every hour to 10 to 15 minutes several times per day. As gradual mobilization improves, many patients need to take a 15 to 30-minute rest once or twice the day to keep back pain and leg pain from returning. If pain can be controlled with the corset and short rest periods, it is better to do that than take NSAIDs or pain medication and mobilize too soon.
Sitting at work, home and in a car are the most common aggravators of symptoms for chronic lumbosacral disc injuries. The highest intradiscal pressures are obtained with sitting with the legs at 90 degrees bent and the spine 90 degrees bent. Sitting intradiscal pressure is higher than prolonged standing or walking. Therefore sitting precautions are frequently required to relieve pain while at work, while at home, or as part of the recovery from injury. Sitting precautions are taken with a variety of measures including spending more time on a kitchen stool, using a cushion on all chairs, elevating the office chair or even getting a standing desk or stool for work. General advice would be that the knees should be well below the hips with the feet on the floor when in the sitting position and this is most effective when used with the corset on.
SHOES AND BACK REHABILITATION
A stable walking/running shoe is mandatory in helping people with low back injuries recover promptly. Frequently, an off-the-shelf arch support such as Spenco Arch Cushion is also required to make walking as comfortable as possible. A shoe can be either part of the problem or part of the solution for back pain. People with low back pain and flat feet or other biomechanical lower extremity alignment issues are aggravated by being in shoes with low heels and shoes that are too soft. A good stable running shoe or Dansko are good examples of a shoe which many people with back problems find helpful. In general, a half inch to one-and-a-half inch heel is more comfortable for people with back pain than a totally flat shoe or too high a heel. Patients who have pain and stand for a prolonged period of time need a specific evaluation for their foot/shoe combination to make sure they are wearing a good supportive shoe with arch supports. Obviously, as a walking program begins, it would be mandatory that a good stable shoe with a good stable arch support be worn while they are progressing to 30-60 minutes of walking a day.
If the patient has pain with walking or standing, assess their shoes for stability, heel height and arch support.
A stable shoe from Brooks, New Balance, Saucony or Etonic would usually be a good choice. Keen and ”Fit Flop” make good sandal choices. Nike Free's, Converse, Vans, Uggs, minimalist shoes and basic flip flops are poor choices.
Soccer with a Corset