Physiotherapy in Crowfoot NW for Pain Care

For pain involving the arms, an incision for the device is made on the side of the chest and the wires are placed in the upper back.

A wireless controller that you should keep with you at all times controls the stimulator device. The controller allows the stimulator to be programmed to adjust the type and strength of the electric stimulation. The spinal cord stimulator is not necessarily permanent and may be removed if necessary. The battery generally lasts two to five years at which time the device must be removed surgically and the battery or the device replaced.

What happens after the procedure?

You will need to lie down as much as possible for 12 hours following your surgery. Your surgeon will allow you to take pain medication for the first few days following surgery. Narcotic pain medications can cause constipation and laxatives may be necessary to have regular bowel movements. You may be asked to avoid the use of an anti-inflammatory such as aspirin, ibuprofen, or naproxen, as they can cause bleeding.

You will be asked to avoid bending, twisting, stretching, reaching overhead, or lifting objects over five pounds for the first six to eight weeks. This is to avoid movement of the wires that connect the device to the electrodes. You will probably not be allowed to drive for two to four weeks after the procedure. Sexual activity may also be restricted initially.

You should expect some mild swelling and bruising at the incision site. Ice packs may help with pain and swelling. There will be sutures or staples and a dressing covering the incision. Call your doctor immediately if you run a temperature, or notice redness, swelling, separation, or drainage from the incision, which can all indicate that an infection has developed.

You will be allowed to shower but you should not bathe or submerge your incisions for four weeks. Watch for visible swelling or leaking of fluid from the incisions. You should wear loose clothing over the incision sites. If you should have sudden weakness of your legs, loss of bowel or bladder function, or sudden severe back pain, you should call your surgeon and go to the emergency department. It may indicate pressure on the spinal cord, a complication that could require emergency surgery.

You will be given instructions on how to operate your spinal cord stimulator. Usually one or two hours of stimulation, three to four times a day is enough to relieve pain for the rest of the day. You should expect 50 to 70 percent improvement in your pain. The device should be turned off when driving and operating machinery or power tools. Electronic systems that contain magnets will need to be avoided as they can interfere with the electrical current from your device. These include security systems found in libraries and airports. Strong X-rays, ultrasound, and magnetic resonance imaging (MRI) should also be avoided. Microwaves, cell phones, pagers, and anti-theft sensors will not affect your stimulator. You will be given an identification card that can be shown to airport and other security officials when necessary. The ID card can also be used in the event of a medical emergency, as it is important for medical providers to know about the implanted device.

You will have a follow up appointment with your doctor seven to 10 days after surgery to remove sutures or staples. Your surgeon may make adjustments to the device at this and other follow-up appointments.

Physiotherapy at Interactive Health Physiotherapy & Massage after spinal cord stimulation implantation surgery can begin as soon as your surgeon recommends it.  Learning to activate the deep muscles of the abdomen and low back area (core) that support the spine can be done nearly immediately without putting stress on the implanted stimulator or electrodes; no twisting, bending, or stretching is required. Your therapist will teach you how to activate these muscles with an isometric contraction where you tighten the muscles but don’t move the trunk.  They will ask you to gently contract these muscles as you do your daily activities. These core muscles, when activated, work like an internal brace that help to support the spine. You may have learned how to use these muscles during physiotherapy treatment prior to the spinal cord stimulator being implanted. After the implantation, activating these muscles may feel different due to a decreased level of pain. You will likely be able to more effectively activate these muscles due to the lower level of pain you feel, which will be beneficial for you back problem overall. For this reason, it is important to follow up with your physiotherapist after the surgical implantation despite any therapy you have undertaken prior to the surgery.  In addition, the surgical incision and procedure itself is considered a new ‘controlled injury’, which in itself affects the ability to activate and control your trunk muscles so re-learning to use these muscles post-implantation is essential. Physiotherapy at Interactive Health Physiotherapy & Massage can ensure that you are using the muscles as effectively as possible to support the spine after your implantation surgery.

Further physiotherapy treatment will usually not be commenced until after the 6-8 week mark when your restrictions as outlined above have been lifted. This amount of time allows scar tissue to form around the electrodes and wires in order to keep them in place before doing any significant movements with your trunk and back. Your surgeon will advise you when the appropriate time to lift the restrictions in your individual case is.

Once it is safe to do so your physiotherapist will assess other important areas of your body that help to support the spine, such as your hips. They will assess both the range of motion of your hips as well as the ability of your gluteal (buttocks) muscles to support the hips and back. If your hip range of motion is poor or your gluteals are not strong enough then extra stress is transferred to your low back.  Often because you feel less pain in your back after having the spinal cord stimulator implanted you can more effectively strengthen your buttocks muscles than previous to the implantation. The flexibility of the anterior hip muscles as well as the muscles of the front and back of your thigh will also be assessed and stretches may be provided if any muscles are found to be tight or overactive.

Your physiotherapist will also assess your posture and overall alignment, which again is important to address once your pain is at a more controlled level. Many bad posturing habits can develop simply due to chronic pain.  With your pain more under control, addressing these habits and establishing new and more efficient postural positions and ways of moving is essential.  Overall alignment of your trunk and lower extremities will be reviewed and, if necessary, any issues in your knees or ankles contributing to poor alignment (which can affect your back) will be addressed.

In addition to your posture your gait will also be reviewed. Pain does not only affect your static posture but can also cause you to develop an inefficient walking pattern that puts unnecessary stress on joints in the lower extremities and the back.  In a normal day most people take thousands of steps just to get around therefore an inefficient or improper walking pattern can quickly lead to pain either in the back itself or other related joints.  Your physiotherapist will assess your gait and ensure that you are walking properly.

After approximately six to eight weeks, you will be able increase your activity level and start to resume more of your normal activities.  Your physiotherapist will advance your core strengthening exercises at this time frame so that you are doing challenging exercises that progress your strength and endurance without putting any stress on your back.  They will also advise you on returning to your regular daily work and leisure activities.  As soon as it is safe to, they will encourage you to partake in some cardiovascular activity to maintain your overall fitness. Often stationary cycling where you sit upright rather than bending over is manageable as an exercise early on after implantation, as is walking.  Cardiovascular exercises in the pool may also be suggested but should not be done until the incision wound has healed and your surgeon has given you clearance to do so.  The hydrostatic properties of water as well as the warmth of a physiotherapy pool often make exercise less painful so they are encouraged.  It should be noted though, that some spinal stimulators should not be used on stimulation mode while in the pool. Your surgeon can advise you regarding your particular brand of stimulator and its specific activity restrictions.

Participating in more stressful cardiovascular activities such as jogging, weight lifting, or regular sport will need to be discussed with your surgeon to ensure that it is safe to do so in your case. Any jolts of pain or inconsistent sensations may mean your electrodes or wires are shifting slightly; this issue will need to be reviewed by your surgeon.

You will be required to do your rehabilitation exercises as part of a home exercise program. As you become more independent with the exercises and once your therapist is confident that you are progressing as they would expect you to, your visits to Interactive Health Physiotherapy & Massage will become less frequent, and your therapist will act only as a guide.

Should your pain flare up during certain intervals, you may need to follow up with your physiotherapist more frequently until the pain settles.

Interactive Health Physiotherapy & Massage provides services for physiotherapy in Crowfoot NW.

What might go wrong?

Spinal cord stimulation is considered minimally invasive and safe, however there are several complications that may occur during or after this procedure. No invasive procedure is 100 percent foolproof. Complications are uncommon, but you should know what to watch for it they occur.

Infection can occur at the incision site, around the wires, or around the device itself. You should watch for signs of increasing redness, swelling, pain and fever. Almost all infections will need to be treated with antibiotics. When the infection involves the spinal canal, it may be more serious. A condition called an epidural abscess may form inside the spinal canal. This infection can cause a large pocket of pus to form around the nerves putting too much pressure on the nerves. If this complication occurs, you will probably need a surgical procedure to drain the infection and remove the pressure from the nerves. The device, the electrodes and the wires will need to be removed. Antibiotics will also be necessary to treat the infection.

An epidural hematoma can occur which happens due to excessive bleeding into the spinal canal. The bleeding can cause pressure on the spinal cord. This, in turn, can cause paralysis or loss of movement of the limbs. Loss of bowel and bladder function can also occur. This complication requires emergency surgery to drain the hematoma and relieve the pressure. The spinal cord damage can be permanent.

A pneumothorax is the collapse of a lung. A lung can be punctured when needles are inserted in the area of the chest or upper back. If the pneumothorax is small, then it may only require monitoring for several days until it resolves. If it is severe and interferes with your breathing, a chest tube may need to be inserted to re-inflate the lung.

Damage to the spinal sac during the insertion of the electrodes may cause a persistent spinal fluid leak. The symptom that you will experience if this occurs is a very bad headache. The headache is worse when you are sitting or standing upright. It may cause nausea and vomiting and will go away if you lie flat or with your head a bit lower that your feet.  The headache occurs because the spinal fluid pressure in the skull decreases. This is the reason why the headache goes away when you lie down; the spinal fluid pressure goes back to normal in your skull. Most spinal headaches go away in a few days when the hole in the spinal sac heals and closes on its own. You may be instructed to stay flat for a couple of days until this occurs. If your headache lasts longer than 48 hours despite lying down as instructed, call your surgeon. In some cases a spinal fluid leak may require surgery to correct.

Nerve damage caused by needles and electrodes placed in the area of the spinal cord may occur. Even paralysis that could be permanent can occur.

Allergic reactions can occur, usually to medications or dye used during the surgery. A severe allergic reaction called anaphylaxic shock can be deadly.

A seroma is the collection of fluid that develops in the pocket around the implanted device. It can last several weeks or months. Your surgeon can drain the fluid. If the fluid in the seroma becomes infected, the device must be removed and the infected fluid drained.

Finally, technical problems or failure of the device can occur. The electrodes may slip out of position. This may change the area of stimulation and could reduce or eliminate the effectiveness of the pain relief. The wires or the electrodes can break leading to failure of the device.

It is important to remember that the spinal cord stimulator is not a cure for your pain; it is only a part of your overall pain management plan.  Along with using the device you will still need to continue working with the other recommendations from your therapist, surgeon, and other healthcare professionals in your pain management team.

Portions of this document copyright MMG, LLC.