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Old 11-23-2006, 08:48 AM
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Harrison Harrison is offline
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Alfons Kagermeier -- Age 29
Pro-Spine Physiotherapist
Straubing, Germany November 2006

Patients around the world often question the role of physical therapy after having an ADR procedure. Some patients pace themselves very slowly and carefully, while others pursue physical therapy aggressively. Somewhere between the two extremes, most patients find a balance and ease back into normal activities.

As we have seen through patients on this forum, there are substantial differences among post-op therapy recommendations in the U.S. When we look at post-op therapies in the European PT programs, these differences are even starker.

We spoke with Alfons Kagermeier, a Pro-Spine Physiotherapist working for Dr.(s) Bertagnoli and Fenk-Meyer, to better understand the Pro-Spine approach to helping their spine patients recover from spine surgery.

ADRSupport: What is a physiotherapist? What training and certification did you receive to be able to practice? How much experience (in years) has the physiotherapist has in treating spine surgery patients? In arthroplasty patients?

Alfons: It may be best to start with trying to explain the European system as I know it. I have an initial education of post graduate work of three years. I understand this is the best way to describe it, as I am told the education systems are different between America and Germany for instance. The physiotherapy program is highly selective, with very high standards, meaning, for example, I was one of 27 chosen out of 700 applicants. After three years of Physiotherapy education, I worked privately for one year, followed by 2 years of intensive work and education specifically with Dr. Bertagnoli. This included assisting in well over 300 surgeries per year, as well as, extensive hours post-op with patients. These patients are roughly 90% arthroplasty.

ADRSupport: What is your role at Pro-Spine?

Pre-op and post op physiotherapy and assisting during surgery.

How do you help patients recover?

I do a lot of listening and explaining the techniques, surgical approach, etc. I strive to facilitate good communication.

ADRSupport: Tell us more about the techniques you employ to help people recover.

Alfons: Traditionally, it’s my understanding we as European PT’s provide far more manual therapy. Only on specific cases do we use machines. I understand this is somewhat different than my stateside colleagues, although I personally have no knowledge of American PT techniques. This is just the feedback I get from patients. A typical session involves 30 minutes to one hour of manual therapy; this may also include muscle strength training, but only after a significant amount of healing and balance of the entire body has occurred. Every patient is an individual as well as their recovery.

ADRSupport: What are some of the “do’s” and “don’ts” during a patient’s recovery; e.g., during the first six months?

Alfons: “LISTEN to your body”! No maximum flexion, extension or rotation, no extreme physical labor for 3 to 6 months. After 6 months, you are allowed to return to normal activities, BUT this still means YOU must listen to your body and not do stupid things. Defining normal for some people can be difficult.

ADRSupport: Are their guidelines that you follow to interpret how to advise and treat patients? And do you provide any kind of activity guidelines for your patients? What materials if any do you provide to them?

Alfons: We provide a handout that we created with Dr. Bertagnoli, myself and Anita. It was helpful to have her modify for not only the English, but she has a better understanding of USA PT as well as the American mindset towards recovery. This can be very different from the typical German thought process of recovery. This handout explains the exact process of the procedure to opening and closing in order to give the patient and their doctor or PT or Massage therapist or health care person to understand exactly which parts of the anatomy are involved during the surgery. This is not on operative report, just a step-by-step breakdown of the surgery process.

This was created so that any good PT or therapist that has a thorough understanding of anatomy can understand exactly what was done and can create a better post-operative plan along with the patient. We want to fully inform the patient so they take full part in the recovery program should they seek follow-up care. If the person they choose does not understand the handout and is not interested in seeing your pre and post-op x-rays, then find another therapist. We cannot control the PT from Germany; we try to explain the best we can what has happened and to help them choose what is best for them. Many patients do not choose PT because they have already had months and years of this.

We try to advise and treat by getting to know the patient, e.g., were they a golfer, computer programmer, or do they just want to be able to pick up their child again?

ADRSupport: What should patients be mindful of during their recovery?

Alfons: Always the same, listen to your body, there will always be peaks and valleys and you’ll notice that you will gradually reach a plateau as the ligaments adapt and the soft structures and facets, and the whole body to this new alignment.

ADRSupport: Have you proven, in any way, that certain PT techniques are beneficial to a patient’s recovery?

Alfons: For some, its osteopathy, cranial-sacral therapy, myofascial therapy, manual therapy, it’s usually a combination that is indicated for the individual patient. I have to say, NO CHIROPRACTIC MANIPULATION OF THE IMPLANT.

ADRSupport: What is the effect on posture by disc replacement?

Alfons: Normally, it returns a person to a “normal” physiological lordosis of both the cervical and lumbar spine.

ADRSupport: What are the recommendations before returning to a "heavy job" following disc replacement?

Alfons: See above, final x-ray controls, this means having x-rays at 3,6,12,24 and yearly thereafter. Pro-Spine patients can send their Xrays to Pro-Spine at these intervals for review and an assessment via e-mail.

ADRSupport: What exercises are recommended for the 'inner layer' of paraspinal muscles?

Alfons: Core strengthening is the most important and first step, which can be as simple as walking and swinging the arms normally or segmental stabilization with your PT. Important muscles are the multifidus, rotatorious, and abdominal muscles, however these can be very difficult to isolate (but highly effective in terms of core strengthening).

ADRSupport: What is splinting?

Alfons: Muscle Splinting occurs when trauma is introduced to an area or there is pain. For example, in a disc herniation, the supporting structures (ligaments , tendons, muscles) “splint” the area -- think of splinting a broken bone. It’s the same, the body’s natural mechanism is to aid and protect an affected area. However, this very same splinting can create more pain, decrease mobility and create muscle spasms, (that feeling when your back goes out). The body adapts, but this can be very painful too. A back problem is like an onion; it has many layers, like splinting, with the source in the middle.

ADRSupport: Is hanging from a chin-up bar too stressful for an artificial spine joint, whether it is a constrained or unconstrained design?

Alfons: No, after 6 months it is acceptable.

ADRSupport: What are the surgeons recommended activities upon returning home after surgery (some say to just let your body dictate what you can and cannot do)?

Alfons: See above.

ADRSupport: What about activities in these post-op periods? 0-6 week period? 6-12 week period? 12-24 week period? 6 month?

Alfons: 0-6 weeks, Just walk, rest, walk rest, normal life is good PT. Keep moving, many short walks are better than one long one, remember, you are retraining your entire body how to walk and adapt to your new posture, this must happen neurologically also, and it does, by walking and normal activities.

6-12 weeks. Again walk, swim, but nothing vigorous, it depends upon the surgery, and the bone density of the patient…until the critical 12 week mark when the bones are continuing to grow into the implant. Remember to listen to your body and avoid maximum flexion, extension and rotation. Tying your shoes is maximum flexion, but do it SLOWLY, listen to your body, it will tell you when to modify your behavior.
It takes a good three to 6 months for the bone to grow well into and around the implant.

12-24 weeks. At this point it is possible for some patients to begin a gentle core strengthening program, along with the continued walking, easy swimming (non-competitive). Just walking in water is great exercise and core strengthening (after your wound is 100% healed)

ADRSupport: How much or how many PT visits are necessary for a particular individual, depending on age, extent or surgery?

Alfons: Remember, Dr. Bertagnoli sees many difficult and multilevel cases, each PT and recovery program is different and is why we cannot have an “across the board program” for everyone.

ADRSupport: At what time period can I participate in passive activities, such as; yoga, Pilates, etc. versus aggressive activities such as jogging, running, golf, etc.?

Alfons: In my opinion, yoga can be too much motion in this area; the bone ingrowth around the implant needs about three to 6 months. Jogging, running, golf is later, why rush things? This is the difference in USA and German culture -- American patients want an exact time and program. In healing, everyone is different, the time to do more or less, is different. You must listen to your body. Use common sense.

ADRSupport: What are some of the "normal" recuperation twinges and pains versus distraction pain, muscles spasms?

Alfons: A little burning is possible for quite some time, some distraction pain around the facet joints because of new alignment and more mobility. Muscles and ligaments will complain because they have to adapt. Normal activities are best; icing can be too passive. Just keep moving and listen to your body! I cannot say this enough. A patient must use common sense. That said, I even had one patient ask me, (honestly),“What is common sense”? So, there you go. Human nature is what it is.

ADRSupport: Alfons, thank you very much for your time and insights -- Vielen Dank für alles.

Alfons: Du bist willkommen.
"Harrison" - info (at)
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Old 12-15-2015, 12:58 PM
Disc replacement 2015 Disc replacement 2015 is offline
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Join Date: Dec 2015
Posts: 150
Default Handout?

HI Harrison,
Any chance you have a copy of the handout this post refers to?
Canadian but not into hockey (even as a woman I'm a shame to the country lol).
Sporadic back problems for yrs.
Severe issues 2013. degenerative disc disease 2013, disc protrusion, mild stenosis. Epidural steroid injections, chiro, massage, accupuncture, too many meds to list, Naturopath, physio, occupational therapy, kinesiologist, counselling...
M6 Artificial disc replacement @l5-s1 Nov 2015, in Canada
June 2016 - still struggling...Physio, accupuncture, massage, counselling...
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adr recovery, physiotherapist, physiotherapy program, post-operative recovery, spine surgery, spine surgery rehab

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