PTA 130 Fundamentals of Treatment I Spine and Sacroiliac

Lesson Objectives Identify key anatomical muscles and structures of the spine Identify common tissue injuries, conditions and surgical interventions Analyze restorative interventions for common injuries, conditions, and surgical procedures Identify soft tissue specific mobilizations Identify flexibility, strengthening, functional, and stabilization exercises Identify spinal stabilization techniques

Spine and Sacroiliac

Review Anatomy of the Spine Vertebra, disc- Annulus, Nucleus, Cartilaginous end-plates

Vertebral Column 33 vertebrae 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal 6

Spinal Curves Primary curve Secondary curve Kyphosis: “C” curve Convex posterior Thoracic and sacral regions Secondary curve Lordosis Convex anteriorly Cervical and lumbar regions 7

Spinal Segment Motions of the Spinal Column Use model to demo flex/ext; lat flex, rotation, ant/post shear, lat shear, distract/comp

Motions of the Spinal Column The functional unit is comprised of two vertebrae and the joints in between (2 facet joints and 1 intervertebral joint) Motion at the functional unit is defined by what is occurring with the anterior portion of the body of the superior vertebra Flexion/Extension (Sagittal plane) Lateral Flexion (Frontal plane) Rotation (Transverse plane) Shearing (posterior, anterior, or lateral) Distraction/Compression

Curves Function Dynamically Extension:  lordosis /  kyphosis Flexion:  lordosis /  kyphosis 10

Common Spinal Pathologies Herniated Disk Sciatica Spinal Stenosis Degenerative Disk Disease Compression Fracture Scoliosis Spondylolisthesis Ankylosing Spondylitis

PT Interventions for Spinal Pathologies Acute (0-4 weeks) Soft tissue mobilization/Joint specific treatment Modalities Initiation of gentle core stabilization exercises Instruction in positional stretches Subacute (4-12 weeks) Appropriate muscular endurance and strengthening exercises Postural re-education Chronic (>12 weeks) Conditioning and spinal control during high-intensity and repetitive activities Patient Education throughout all phases

Intervertebral Disk Annulus Fibrosus- Nucleus Pulposus- Outer portion of the disk. Made up of dense layers of collagen fibers and fibrocartilage. It is supported by the anterior and posterior longitudinal ligaments. Nucleus Pulposus- The central portion of the disk is a gelatinous mass that is contained within the annulus fibrosus. Functions to distribute pressure evenly throughout the disk and from one vertebral body to the next under loaded conditions.

Intervertebral Disk During flexion biased activities of a vertebral segment, the anterior portion of the disk is compressed, and the posterior is distracted In a healthy disk, the nucleus pulposus does not move but may present with a slight distortion to redistribute the load through the disk

Intervertebral Disc K&C pg 409 fig 15.3

Nachemson, A. The Load on Lumbar Disks in Different Positions of the Body. From the Department of Orthopaedic Surgery, University of Gothenburg, Gothenburg, Sweden

Intervertebral Disc Terminology Herniation- A bulge of the annulus beyond its normal perimeter Protrusion- Nuclear material still contained by the outer layers of the annulus Prolapse- A rupture of the nuclear material into the vertebral canal Extrusion- Prolapse beyond the confines of the posterior longitudinal ligament or above and below the disk space Sequestration- Extruded nucleus has separated from the disk and moved away from the prolapsed area.

Herniated Disk The spinal disc degenerates or grows thinner. The jellylike central portion of the disc bulges out of the central cavity and pushes against a nerve root. Intervertebral discs begin to degenerate and produce symptoms of nerve impingement.

Terminology Associated with Disk Herniation Peripheralization- Symptoms are experienced farther down the leg Centralization- Symptoms recede up the leg or become localized to the back

Herniated Disk Treatment Modalities for pain control Soft tissue mobilization Joint Specific treatment Disc Specific treatment Mechanical traction Core strengthening exercises Stretching exercises

Sciatica Patient typically presents with pain along the path of the sciatic nerve Usually caused by pressure on or compression of the sciatic nerve. Test: Supine – straight leg raise add dorsiflexion, Slump-sitting test – neck/trunk flexion with knee extension and dorsiflexion Treatment: Piriformis/Hamstring Stretch/ROM Core stabilization Modalities Kisner p 369 SLR with inversion, eversion, adduction – different nerve tracts tested

Spinal Stenosis Narrowing of the space in the spinal canal leading to potential compression of the spinal cord. Congenital or acquired May be caused by disk protrusion, fibrotic scars, bony narrowing, or joint swelling Even minor trauma under these circumstances can cause inflammation and nerve root impingement, which can produce classic sciatica without disc rupture.

Spinal Stenosis (cont’d) Treatment: Positional stretches Core stabilization exercises Modalities Soft tissue mobilization

Degenerative Disc Disease (DDD) Is not a disease, but a degenerative condition caused by wear and tear on the disc Is a natural part of the aging process People will exhibit changes in their discs consistent with a greater or lesser degree of degeneration DDD in the lumber spine leads to narrowing of the nerve root foramen These changes produce painful symptoms Patient may exhibit morning stiffness or pain, difficulty standing for a long periods of time or walking even short distances Disc is relatively aneural

Degenerative Disc Disease Treatment: Disc specific treatment Joint specific treatment Core stabilization Stretching Modalities Posture re-education Instruction in proper ergonomics

Compression Fracture Fracture of the vertebra Causes: Osteoporosis Trauma Tumors Patients often experience pain, numbness, weakness, tingling, and/or increased kyphosis throughout thoracic spine (osteoporosis)

Compression Fracture (cont’d) Treatment: Immobilization (acute phase) Core stabilization exercises Posture re-education Modalities Medication (osteoporosis) Surgery

Scoliosis Abnormal lateral (side-to-side) curvature of the spine with possible rotation (twisting) of the vertebrae within the curve In the thoracic spine, the ribs rotate with the vertebrae so there is a prominence of the ribs posteriorly on the side of the spinal convexity Treatment: Stretching activities ROM activities Core stabilization Modalities

Prolonged Side-Bending Stretch

Spondylolisthesis One vertebra slips forward on the vertebra below It is the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. Treatment: Flexion biased exercise Core stabilization Modalities is on everything? I suggest a general statement that modalities can be used in the initial stage of injury for pain relief for all spinal pathologies? kp

Ankylosing Spondylitis An inflammatory disease that can cause some of the vertebrae in the spine to fuse together A long-term disease that causes inflammation of the joints between the spinal bones and the joints between the spine and the pelvis The spine becomes less flexible Increased kyphosis presents in the thoracic spine Treatment: Stretching, ROM, posture re-education, modalities

Citation from R drive- Instructors “Bamboo Spine” on x-ray

Spinal Pathologies Myofascial pain: Pain and tenderness over localized areas trigger points, loss of range of motion in the involved muscle groups. Treatment: Stretch/ROM, Manual soft tissue, modalities. Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes and fibromyalgia.

Spinal Pathologies Fibromyalgia: Chronic pain condition characterized by widespread pain that covers half the body and has lasted > 3 months. Diagnosis is made by positive tender points in 11 out of 18 sites throughout the body. Treatment: Stretch/ROM, core stabilization, and modalities. *Progress slowly! Muscle damage can occur if overworked, which occurs easily for this population. Aerobic Exercise is the treatment of choice- pg 317 K&C - kp

Common Spine Surgical Interventions Microdiscectomy Small incision at the site Muscle tissue moved out of the way Lamina cut Disc protrusion removed Generally same management as conservative treatment with emphasis on stabilization

Common Spine Surgical Interventions Spinal Fusion- Surgery performed to permanently connect two or more vertebrae in the spine Used to improve stability, correct a deformity or reduce pain Involves placing extra bone (bone graft) to fill the space between two spinal vertebrae IN PROGRESS- kp

Common Spine Surgical Interventions Spinal Fusion Indications Instability Severe DDD Spondylolisthesis Fractured vertebra Chronic pain Precautions- immobilization during protection phase

Spinal Fusion Harrington rods Bone graft Cage Bone Graft

Spinal Fusion Anterior approach Cage Anterior Approach

Spinal Surgery Lumbar Discectomy Lumbar Laminectomy Catalog.nucleusinc.com Lumbar Discectomy Lumbar Laminectomy

Spinal Surgery Catalog.nucleusinc.com Kyphoplasty

Post-Operative Care Follow the Plan of Care Check on spinal precautions and watch for changes in post-operative restrictions Don/Doff brace via log roll technique while in bed, unless cleared by physician to don in sitting or standing Instruct the patient regularly in spinal precautions BLT No Bending, Lifting or Twisting Shot from the hip- not the text kp

Post-Operative Exercise Generally early ambulation Occasionally patient will be on bed rest for a few days Bed Exercise Ankle pumps Quad sets

Post-Operative Exercise Glut Sets Heel Slides Gentle abdominal sets

Principles of Spine Disorder Management Red Flags: Conditions that should be referred to a specialist because the symptoms are thought to fall outside the scope of practice of PT Possible underlying cause of symptoms is pathological in nature and diagnosis from a medical doctor is warranted Possible life threatening conditions

Principles of Spine Disorder Management Psychological Considerations Psychological distress, depression, anxiety may impede the patient’s recovery and prolong pain and dysfunction May also require referral to the appropriate medical or psychological professional

Spinal Orthotics

LUMBOSACRAL CORSET

CERVICAL ORTHOSES/COLLARS Soft Collar Philadelphia Collar

Cervical Halo Non invasive and invasive brace

TLSO

Scoliosis: Milwaukee Orthosis The other, less common, type of brace used is the Milwaukee Brace. This brace is used to restrain particularly high curves.   Fitted in the same way as the Boston Brace, the Milwaukee Brace contains a wide flat bar in front and two smaller ones in back. These bars attach to a ring around the neck that has rests for the chin and back of the head. Unlike the Boston brace, the Milwaukee brace is quite noticeable even when worn under clothing. Both the Milwaukee and Boston Brace may need to be periodically adjusted for growth. I grew several inches while in both braces, so every few months I had to return to the orthotist so he could adjust my brace. The orthotist also re-molded my brace to properly fit my chest and hips when it started rubbing too much and causing pain.

Scoliosis: Boston Brace The most common type of brace is the Boston Brace (also known as a TLSO brace or underarm brace). This brace is fitted to your body and custom molded from plastic. The Boston Brace works by applying three-point pressure to the curvature to prevent its progression. There are usually Velcro straps on the back of the brace that you gradually tighten over the course of wearing it. The tightening is necessary to ensure that constant pressure is applied to the correct parts of the spine in order to restrain the curvature

Therapeutic Interventions for Spinal Disorders

Common Spine Conservative Treatment Flexion Bias- Flexion Syndrome (symptoms decrease with flexion) Extension Bias- Extension Syndrome (symptoms decrease with ext.) Segmental Instability (Hypermobility)- Lumbar Stabilization (Core Stabilization, Core Muscle Activation, Abdominal Bracing) Mobilization for Hypomobility- Manipulation Non-weight-bearing Bias- Traction Syndrome Talk about the “CPR” Clinical Prediction Rule-kp K&C pg 431

Williams’ Flexion Exercises Devised by Paul C. Williams (orthopedic surgeon) in 1937 Enhances lumbar flexion and avoids lumbar extension Seven exercises for chronic low-back pain (LBP) Emphasis on flexion Strengthening of abdominal and gluteal muscles Stretching of hip flexors and erector spinae 62

Curl-Ups

Posterior Pelvic Tilt

Single Knee to Chest (SKTC)

Double Knee to Chest (DKTC)

McKenzie Extension Program Robin McKenzie: New Zealand physiotherapist Believed the disc to be the primary cause of back pain in most individuals Predisposing factors in back pain: Prolonged sitting in flexion Frequency of flexion Lack of extension Emphasis on extension to relieve disc pressure 67

McKenzie Mechanical Syndrome Classifications Postural: Low back pain is the result of prolonged postures or positions that can affect joint surfaces, muscles or tendons Dysfunction: Adaptive shortening, scarring or adherence of connective tissue causes discomfort Derangement: The most common syndrome that presents clinically Patient is sensitive to certain movements and particular movement patterns When certain movements are performed, such as a flexion and/or extension the symptoms become less intense or centralize 68

Prone Lying

Prone Press-Ups

Progressive Extension

Standing Extension

Lumbar Stabilization What key muscle groups need to activate in order to provide optimal stabilization to the lumbar spine? Transverse abdominis Multifidus muscles

Techniques for Abdominal Muscle Activation Three techniques used most often: “Drawing In” Maneuver Abdominal Bracing Posterior Pelvic Tilt Each technique differs in the stabilization activity of the abdominal and multifidus muscles

“Drawing In” Maneuver Isometric core stabilization exercise The most effective way to activate the Transversus Abdominus and Multifidus Progress through a series of stabilization exercise, then to functional exercise The patient is encouraged to activate the core musculature consciously and maintain a neutral spinal position until it becomes habitual K&C Pg 454 fig 16.2 talks about 3 different methods of activating stabilizing musculature

Neutral Spine Begin with the patient in supine – hook-lying position Have patient perform a posterior pelvic tilt (flatten back)- place your hand under the patient for tactile cue Then have the patient perform an anterior pelvic tilt (arch your back) Instruct the patient that he/she should not feel either one of those moves during the stabilization exercises but rather try to maintain their neutral spine position It is through the contraction of those muscles controlling the movement that strengthening and control occur

Cervical Stabilization K&C pg 453 fig 16.18

Spine Stabilization With Arms

Spine Stabilization With Unsupported Arms and Legs

Quadruped Arm Raise

Quadruped Arm and Leg Raise

Posterior Pelvic Tilt

Bridging Progression

Therapeutic Interventions for Spinal Disorders Mobilization for Hypomobility- Manipulation Grade I-IV mobilization Spinal Manipulation (Grade V) Non-weight-bearing Bias- Traction Syndrome Self Traction techniques Mechanical Traction- Cervical or Lumbar

Tennis Ball Self Release Technique

Sacroiliac Joint

Sacroiliac Joint

Sacroiliac Joint Kinematics A weight bearing joint formed by the union of the sacrum and ilium bones on either side of the pelvis Reinforced by very strong ligaments in the pelvis Slight motion occurs at this joint Transmits all the forces of the upper body to the pelvis and legs Allows for multiplanar rotation and translation Nutation: anterior rotation of sacrum relative to ilium Counternutation: posterior rotation of sacrum relative to ilium 90

Spinal Pathologies SIJ Dysfunction Treatment: A term used to describe various sacroiliac injuries or dysfunctions May refer to either hypo or hyper mobility Can cause problems with surrounding structures as well as symptoms into lower back and buttocks, thigh or groin Treatment: Core stabilization, muscle energy technique, modalities

QUESTIONS?