1. Physical Rehabilitation of the Degenerative Spine
18th Annual Primary care orthopAedic and sports medicine symposium
January 26th, 2018

2. Disclosures
No financial and/or conflicts will be discussed

3. Amanda Blume, PT, DPT, ATC at Rib Mountain sport and spine clinic
Karissa Clark, pTa at rib mountain sport and spine clinic

4. objectives
Formulate treatment plan for patient based on patient presentation and diagnosis
Identify appropriate exercise and treatment based on diagnosis to address limitations or dysfunctions
Implement appropriate self-management techniques

5. Low back pain diagnoses
Ankylosing spondylitis
Degenerative spondylolisthesis
Lumbar stenosis
Lumbar spinal stenosis=
Ankylosing spondylitis =
Degenerative spondylolothesis=

6. Presentation and evaluation
Ankylosing spondylitis and spondylolithesis
Mandible protrusion
Forward head
Shoulder protrusion
Scapular protraction
Thoracic hyperkyphosis
reversal of lumbar lordosis
Increased posterior pelvic rotation
Flexion with internal rotation of hip
Flexion at the knees
Decreased peripheral joint mobility
Sacroilliac dysfunction
Evaluation
Ankylosing spondylitis and spondylolithesis
Visual examination of patient
Palpation
Lumbar rom
Flexibility
Stork test
Stand on one foot. Extend lumbar spine. Pain = possible pars fracture
Strength
Sensation
reflexes
After the initial evaluation. The findings may reveal:
Hyperlordotic posture
Lumbar tenderness
Hamstring tightness
Hip flexor tightness
Pain with extension
Pain with single leg hyperextension
palpated stop off of spinous process

7. Presentation and Evaluation
Lumbar Stenosis
Unilateral and/or bilateral leg pain
Decreased balance
Cramping that is resolved with sitting
weakness
Evaluation
Lumbar Stenosis
Visual Examination of patient
Palpation
Neuromuscular exam
Strength
Pelvic position
flexibility
After the initial evaluation, the patient’s examination may reveal:
Tight hip flexors, iliopsoas and rectus femoris which may increase rotation at the pelvis
Early recruitment of lumbar extensors leading to weakness in the hamstrings, glutes, then abdominals
Decreased lumbar extension
Decreased ankle reflexes
Positive straight leg raise test

8. Fritz 2007; 37(6), 291

9. Treatment session Initial Evaluation = 45-60 minutes
Frequency and Duration
Pt Sessions = minutes
Manual therapy
Therapeutic Exercise
Therapeutic Activity
Neuromuscular Re-education
Modalities
Ultrasound, Electrical stimulation, heat or ice, Mechanical traction, phonophoresis

10. The ultimate plan Preserve good muscle tone
Prevent further degeneration of ankyloses
Improve mobility of spine and lower quadrant/lumbopelvic region and hip joint
Improve pain
Implement and educate a home exercise program for lifetime learning
Prevent the need for surgical intervention

11. Fritz 2007; 37(6), 298

12. Manipulation
Manipulation may be used to address joint dysfunction or restriction based on results of initial evaluation
MET for lLD

13. Stabilization
Stability dysfunction appears to present as a dysfunction of the recruitment and motor control of the deep segmental stability system resulting in poor control of the neutral joint position (cumerford 2001)
Retraining is important at a local and global level for increased carryover to improve functional outcomes
Excessive extension, hperextension, along with rotation are risk for developing aggrevating spondylosis and spondylolisthesis
Deep multifidi exert compressive forces and aid in spinal motion at the segmental level

14. Fritz 2007; 37(6), 294

15. Specific Exercise
Developed for each individual patient based on examination
Stretch reflex
Local and global strengthening
There is no defined protocol to which specific exercises are appropriate for the disease ankylosing spondylosis
Stretch reflex promotes eccentric isometric contractions. This inhibits the agonist muscle and stimulates antagonists allowing muscle spindle to stretch. This increases mobility and decreases stiffness

16. Cumerford 2001; 6(1) 13

17. Modalities Spinal Traction Ultrasound Electrical stimulation Heat/ice
Spinal traction to increase joint spaces

18. Home Exercise Program and Self-Management skills
Each program is specifically designed with the patient’s needs in mind
Programs are developed throughout the course of treatment
Patient education is a key component to the compliance of the program
Group physical therapy shows significantly better results with morning stiffness, spinal mobility and functional capacity than individual exercises carried out at home

19. Fritz 2007; 37(6), 292

20. What is the Goal?
Increase patient’s awareness of positive affects of physical therapy versus surgery for long-term benefits of patient’s suffering from low back pain
Increase patient’s awareness of positive affects of physical therapy with reducing pain, improving mobility of spine, increasing stability of extensor spinae musculature, and developing self management skills to prevent surgery for long-term benefits of quality of life

21. Surgery vs Non-surgery
No significant differences are found
Non-surgery showed modest improvements overtime, willing to adhere to the program due to not wanting surgery
More patients drop out of usual care than from early physical therapy groups

22. conclusion
Current research suggests that lss patients can see benefits from physical therapy interventions
The recently published report of the international paris task force on back pain summarized the evidence for patients with acute lbp by stating “it appears that the key to success in physical activity itself (i.e. activity of any form) rather than any specific activity.”

23. references
Comerford, m, Mottram, s. Functional stability re-training:principles and strategies for managing mechanical dysfunction. Harcourt 2001; 6(1), 3-14
Fritz, J. Early physical therapy vs usual care in patients with recent-onset low back pain: a randomized clinical trial. JAMA 2015;314(14),
Fritz, J. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. JOSP 2007; 37 (4),
Garet, M, Reiman, M, Mathers, J, Sylvain, J. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systemic review. NCBI 2013; 5(3),

24. references
Scollon-grieve, K, May, J, Chou, L. Lumbar Spndylolysis and spondylolisthesis ;
Silva, E, Andrade S, Vilar M. Evaluation of the effects of global postural reeducation in patients with ankylosing spondylitis. Rheumatol int 2012; 32,
Weinstein, J, Tosteson, T, Lurie, J, Blood, E, Herkowitz, H, Cammisa, F, Albert, T, Boden, S, Hilibrand, A, Goldberg, H, Berven, S, Howard, A. Surgical versus non-operative treatment for lumbar spinal stenois four-year results of the spine patient outcomes research trial. NCBI 2012; 35(14),