Case history summary

• Left foot drop, reported as improving
• Urinary incontinence, reported as improving
• Able to pass stools
• Ambulates more than 1,000 steps/day
• Referred for physiotherapy, including nerve stimulation and gait training
• Orthopaedic advice includes lumbar-spine exercise, core strengthening, deep breathing exercise, and Theraband exercise.

Clinical interpretation

Physiotherapy protocol

Key rehabilitation goals

1. Protect the operated lumbar spine and allow healing.
2. Improve safe walking endurance, balance, and confidence.
3. Recover left ankle dorsiflexion and reduce falls from foot drop.
4. Improve trunk control and functional core strength without stressing the fusion/stabilization construct.
5. Monitor neurological recovery, bladder function, wound status, glucose control, and pain.
6. Gradually return to independent daily activity.

Important principle

Phase 1: Current stage, about week 4 to week 6 post-operative

A. Assessment at first physiotherapy visit

• Pain score at rest, walking, sit-to-stand, and night
• Wound healing, redness, discharge, temperature
• Lumbar movement only within surgeon-approved limits
• Neurological examination:
  • Left ankle dorsiflexion strength, ideally using MRC grading
  • Great-toe extension, plantarflexion, inversion/eversion
  • Light-touch sensation in L4, L5, S1 distributions
  • Reflexes if appropriate
• Gait: foot clearance, toe drag, compensatory hip hiking, need for walking aid
• Timed Up and Go, 10-metre walk, sit-to-stand as tolerated
• Balance: supported tandem stance, weight shifting
• Bladder pattern: leakage, urgency, retention symptoms, ability to sense fullness
• Diabetes monitoring, particularly if activity or electrotherapy is planned

B. Walking and gait re-education

• Continue walking daily, divided into 2-4 short bouts rather than one fatiguing walk.
• Start from the current comfortable distance. Increase weekly by roughly 10-20% only if pain and leg symptoms do not worsen the next day.
• Practice heel strike, controlled tibial progression, and toe clearance on level ground.
• Use a walker or stick temporarily if toe drag, imbalance, or fatigue makes walking unsafe.
• Refer for assessment and fitting of an ankle-foot orthosis (AFO) if left toe drag persists or causes near-falls. An AFO can improve toe clearance during neurological recovery.
• Avoid uneven surfaces, stairs without support, rushing, and walking when fatigued.

C. Foot-drop rehabilitation

1. Active-assisted ankle dorsiflexion
   • Sitting or lying, use a towel/strap or therapist assistance.
   • 2 sets of 10 repetitions, 1-2 times/day.
2. Ankle pumps and circles
   • 20 repetitions, 2-3 times/day.
3. Toe raises in sitting
   • Lift forefoot while heels remain on the floor.
   • 2 sets of 8-12 repetitions.
4. Theraband dorsiflexion
   • Begin only when active dorsiflexion is present and the therapist confirms safe technique.
   • Low resistance, 2 sets of 8-10 repetitions, on alternate days.
5. Functional electrical stimulation or NMES
   • May be considered by the treating physiotherapist for the tibialis anterior/peroneal nerve pathway if there is partial nerve continuity and an observable muscle response.
   • It should be individualized after sensory and skin assessment. Avoid placing electrodes over the lumbar surgical site. Use extra caution in diabetes because reduced sensation and skin vulnerability raise the risk of irritation or burns.

D. Early spinal protection, mobility, and circulation

• Deep breathing: 5-10 slow diaphragmatic breaths, 3-4 times/day.
• Ankle pumps: 20 repetitions hourly while awake during prolonged sitting.
• Log roll for bed mobility.
• Sit-to-stand from a firm elevated surface, keeping the spine neutral.
• Gentle supported weight shifts in standing.
• Gentle hip and knee range-of-motion exercises, avoiding forced lumbar flexion.

E. Early core activation

1. Abdominal brace / transversus abdominis setting
   Gently draw the lower abdomen inward without holding the breath.
   Hold 5 seconds, 8-10 repetitions, 1-2 times/day.
2. Pelvic-floor contraction if appropriate
   Since urinary symptoms are improving, this may help only after bladder assessment and with the surgeon/physician’s clearance. Do not use this as a substitute for urgent medical review if symptoms worsen.
3. Gluteal sets
   Hold 5 seconds, 10 repetitions.
4. Heel slides
   Keep the lumbar spine neutral.
   1-2 sets of 8 repetitions each side.
5. Supported mini-marching in supine
   Only if trunk control is good and it does not increase back or leg symptoms.

Avoid during this phase

• Repeated or end-range bending, twisting, and combined bend-twist movements
• Sit-ups, crunches, straight-leg raises, planks, and heavy resistance training
• Running, jumping, cycling outdoors, manual work, or impact exercise
• Heavy lifting or pushing/pulling
• Prolonged sitting. Change position regularly, initially about every 20-30 minutes if comfortable.
• Aggressive hamstring or neural stretching if it reproduces leg pain, tingling, or weakness.

Phase 2: Approximately week 6 to week 12, only after surgeon clearance

Progressions

• Increase walking duration and include supervised gentle inclines only if gait is safe.
• Stationary bicycle may be introduced if the surgeon permits and the incision has healed.
• Progress abdominal bracing to:
  • Bent-knee fallout
  • Marching
  • Bridge progression
  • Quadruped weight shifts, then supported bird-dog progression
• Hip strengthening:
  • Standing hip abduction and extension with light Theraband
  • Mini-squats with a neutral spine
  • Step-ups on a low step with hand support
• Balance:
  • Supported single-leg stance
  • Tandem stance and controlled direction changes
• Continue dorsiflexion strengthening and gait retraining.
• AFO need should be reassessed as ankle strength returns.

Phase 3: Beyond 12 weeks, after radiographic and surgical review

• Advance resistance gradually for hips, legs, ankle dorsiflexors, and trunk.
• Functional lifting education: hip hinge, load close to body, avoid twisting under load.
• Progress walking distance and terrain as gait and balance permit.
• Consider aquatic exercise only once wound healing is complete and the surgeon approves.
• Return to work and household tasks should be individualized. Heavy/manual work often needs a longer recovery period after lumbar stabilization.

Home exercise schedule at the current stage

Red flags requiring urgent medical assessment

• New or worsening foot/leg weakness, repeated falls, or inability to lift the foot
• New numbness in the saddle/perineal area
• New urinary retention, loss of bladder control, inability to pass urine, or worsening bowel control
• Severe or rapidly worsening back/leg pain
• Fever, wound redness/warmth, wound discharge, or wound opening
• Calf swelling/pain, chest pain, or breathlessness

Medication and safety note

• Check blood glucose as advised, especially around exercise sessions.
• Ensure good footwear and daily skin inspection, particularly if an AFO or electrical stimulation is used.
• Monitor dizziness or postural symptoms during gait training.