Lumbar Facet Syndrome Rehabilitation Protocol

This protocol provides a guideline for physical therapy rehabilitation following a diagnosis of Lumbar Facet Syndrome. It is designed to be progressive and individualized based on the patient's specific presentation, pain levels, functional limitations, and response to treatment. Clinicians should modify this protocol as necessary to meet the unique needs of each patient. Communication with the referring physician is crucial throughout the rehabilitation process.

Pathophysiology

Lumbar Facet Syndrome refers to pain arising from the facet joints (zygapophyseal joints) of the lumbar spine. These joints, located posteriorly, guide spinal motion and provide stability. Pain can result from various factors including:

• Degenerative changes (osteoarthritis)
• Trauma (e.g., whiplash, fall)
• Repetitive stress
• Synovial inflammation
• Joint capsule sprain

Pain is often localized to the lower back but can refer to the buttock, hip, and thigh. Typically, pain is exacerbated by extension, rotation, and prolonged standing or sitting. Muscle spasm is a common secondary finding.

Common Special Tests

• Lumbar Quadrant Test: Reproduction of pain with combined extension, side bending, and rotation towards the affected side is suggestive.
• Kemps Test: Reproduction of pain with lumbar extension, lateral flexion, and rotation.
• Spring Testing (PAIVMs): Palpation and assessment of intersegmental mobility of the lumbar spine. Restricted movement and pain indicate potential facet joint involvement.
• Prone Instability Test: Patient prone with legs hanging off the table. Painful palpation of the spinous process is noted. Then, the patient actively lifts their legs off the floor. If pain decreases or resolves, it suggests lumbar instability contributing to the facet pain.
• Facet Joint Injection (Diagnostic): Injection of local anesthetic into the facet joint. Significant pain relief after injection strongly supports the diagnosis. (Performed by a physician)

Phase I: Protection (Acute Phase - 0-4 Weeks)

Goals: Reduce pain and inflammation, protect the injured tissues, restore initial range of motion, and initiate core stabilization exercises.

• Pain Management:
  • Modalities: Ice, heat, electrical stimulation (TENS), ultrasound to reduce pain and muscle spasm.
  • Manual Therapy: Gentle joint mobilization (Grade I & II) to reduce pain and improve joint mobility, soft tissue mobilization to address muscle spasm.
  • Education: Proper posture, body mechanics for lifting and ADLs, avoiding aggravating activities (extension, prolonged standing/sitting).
• Range of Motion:
  • Gentle lumbar flexion exercises (e.g., knee-to-chest, pelvic tilts) to improve mobility and decrease pain. Avoid extension-based exercises.
  • Cat-Cow stretches (modified to avoid excessive extension).
  • Rotation stretches within a pain-free range.
• Core Stabilization:
  • Diaphragmatic breathing exercises to promote relaxation and engage the deep core muscles.
  • Transverse abdominis activation (abdominal drawing-in maneuver) in various positions (supine, quadruped).
  • Pelvic tilts (anterior and posterior) to improve core awareness.
• Activity Modification:
  • Avoid activities that exacerbate pain.
  • Use proper body mechanics during lifting and other activities.
  • Maintain a neutral spine posture.

Phase II: Loading (Subacute Phase - 4-8 Weeks)

Goals: Improve pain-free range of motion, increase core strength and endurance, improve spinal stability, and begin functional activities.

• Pain Management: Continue as needed from Phase I, gradually weaning off modalities as pain decreases.
• Range of Motion:
  • Progress range of motion exercises as tolerated.
  • Introduce gentle lumbar extension exercises if pain allows.
  • Standing lumbar stretches (e.g., side bending, rotation).
• Strengthening:
  • Progress core stabilization exercises:
    • Dead bugs
    • Bird dog
    • Plank (modified)
  • Begin strengthening exercises for surrounding muscles:
    • Glute bridges
    • Hip abduction/adduction exercises
    • Hamstring curls
    • Quad sets
  • Bodyweight squats (modified as needed).
• Spinal Stabilization:
  • Progress dynamic core stabilization exercises:
    • Carries (e.g., Farmer's walk)
    • Resisted rotation exercises with bands
  • Focus on maintaining a neutral spine during functional activities.
• Aerobic Conditioning:
  • Low-impact activities such as walking, cycling, or swimming.
  • Gradually increase the duration and intensity of exercise.

Phase III: Return to Function (Chronic Phase - 8+ Weeks)

Goals: Restore full pain-free range of motion, maximize strength and endurance, return to pre-injury activity level, and prevent recurrence.

• Pain Management: Self-management strategies and as-needed use of modalities.
• Range of Motion: Continue stretching as needed to maintain flexibility.
• Strengthening:
  • Progress to more challenging core strengthening exercises:
    • Plank (full)
    • Side plank
    • Medicine ball exercises
  • Progress to more functional strengthening exercises:
    • Squats (full)
    • Lunges
    • Deadlifts (with proper form and supervision)
    • Rows
• Spinal Stabilization:
  • Advanced dynamic core stabilization exercises:
  • Sport specific activities
  • Work simulation activities
  • Focus on maintaining proper posture and body mechanics during all activities.
• Functional Activities:
  • Gradually return to pre-injury activities.
  • Simulate job tasks or sport-specific movements.
  • Focus on proper technique and biomechanics.
• Education:
  • Continue to educate the patient on proper posture, body mechanics, and injury prevention strategies.
  • Develop a home exercise program to maintain strength and flexibility.
  • Discuss lifestyle modifications to reduce the risk of recurrence.