1. Week # 5 MVC client – continued treatment Lumbar – Pelvis – Hip Complex Treatment approaches

2. PsychoSocial System

3. Case 33 yr old computer, data controller Complete assessment Treatment approach

4. Segmental Stabilizing System- muscles Palpation of multifidus Potential to activate Transversus Abdominis –More cues of pelvic floor to decrease use of IO

5. Muscles of the Core

6. Spine 29( 1): 3-8, 2004 Trunk Muscle Strength, Cross-sectional Area and density in Patients with LBP Randomized to Lumbar Fusion or Cognitive Intervention Exercises Keller et al Exercise patient - cross sectional increase by 12% and density 16%

7. No exercise patient – fusion No change cross- sectional and density decreased

8. Core Kinnections Heather Curilla PT Susan Massitti FCAMT

10. Multifidus contracting = stability

11. Multifidus Activation

12. Lab Assess ability of the Transversus abdominus to contract Assess function of multifidus using palpation and motor firing

13. Treatment Approaches Mobilizations, Manipulations - cautions to mobs end range and manips Exercise Education

14. Therapist factors Subjective assessment Inadequate information Failure to discuss treatment options Consent Insufficient biomechanical examination Physical limitation Lack of confidence Equipment Incompetence

15. Patient factors Lack of consent Mental status Obsession with manipulation Inability to communicate Unable to relax Pain Intoxicated/heavily medicate Inappropriate end feel Instability

16. Bony elements Fractures – presently healing Dislocations - presently healing

17. Bony elements Active infection – osteomyelitis, tuberculosis Congenital anomalies Gross foraminal or spinal canal encroachment on x-ray

18. Neurological Extra segmental pain increase with passive neck flexion Bilateral or quadrilateral multisegmental paraesthesia Hyperreflexia +babinski, oppenheimer, hoffman Clonus Ataxia Neurological spasticity

19. Neurological Bladder and bowel dysfunction Nystagmus Dysphagia/dyshasia Wallenberg’s syndrome ( PICA) Other cranial nerve S/S

20. Spinal cord disease/injury Extrasegmental pain BELOW level of lesion  with PNF Bilateral, quadrilateral parasthesia, weakness, spasm hyperreflexia hyporeflexia below level of lesion Ataxia

21. Vascular considerations Vertebral artery Vascular disease Bleeding disorders Aortic graft

22. Soft tissue Collagen diseases –Ehler’s –Danlos Syndrome –Marfan’s Syndrome –Osteogenasis imperfecta –Achondroplasia –Benign Hypermobility ( Caution)

23. Age Elderly – tissue health Children – consent, skeletal maturity

24. Metabolic Disease Bone Disease Osteoporosis Paget”s

25. Systemic Disease /Condition Diabetes ( caution) Endocrine disorders ( caution) Haemophilia Pregnancy

26. Inflammatory Diseases Active inflammatory disease Rheumatoid Arthritis Ankylosing Spondylitis Psoariatic Arthritis Reiter’s Inactive inflammatory Disease ( caution)

27. Medication Anticoagulants Any med that effects collagen eg corticosteriods, tamoxifen Med linked to osteoporosis Anti-depressants ( caution)

28. References Greenspan, A., Orthopedic Radiology, Lippincott Williams & Wilkins, philadelphia, 2000, 3 rd edition Daffner, R., Clinical Radiology, 2 nd edition, Lippincott Williams & Wilkins, 1999 Grieve, G., Modern manual therapy, 2 nd edition, Churchill and Livingstone, 1994 Goodman & Boissonnault, Pathology; Implications for the physical therapist, W.B. Saunders company, 1998 Level 2 upper manual, 2002 A special thanks to Lenerdene Levesque and Scott Whitmore for the use of pathology slides

29. Treatment Options Mobilization, manipulation Exercise Rehab Muscle Retraining Education

30. Lumbar Traction sustained vs oscillations

31. Unilateral Flexion

32. Lab Demo of Flexion gap manipulation Demo and practice sustained traction, graded flexion with muscle activation

35. Pelvis When to look further Some assessment tools

36. Kinetics of the Lumbo-Pelvic Region The lumbo-pelvic region is required to transmit the weight of the head and the trunk to the lower extremities Also functions to resist the forces incurred by the lower and upper extremities.

37. Transmission of Force

38. Vleeming et al 1990 Form closure Form closure refers to a stable situation with closely fitting joint surfaces, where no extra forces are needed to maintain stability of the system.

40. Clinical Relevance Compare left to right of same patient not normal to abnormal Neutral zone motion requires the analysis of a small range of movement near the joint’s neutral position where minimal resistance is given by the capsule and ligaments

41. Neutral Zone Theory Panjabi describe a small range of displacement near a joints neutral position. He has found that the range of the neutral zone may increase with trauma, degeneration and weakness of the stabilizing structures

42. What can affect the neutral zone?

43. Force Closure Force closure refers to the extra forces required to keep an object in place. The amount of force closure required is dependant on the coefficient of friction of the articular surfaces

44. Force Closure – Ligaments Several strong ligaments connect the innominate and sacrum Ligament tension varies with sacral/innominate position

46. Long Dorsal Lig

47. Self- locking ( CPP) of the SIJ Nutation of the sacrum tightens the major SIJ ligaments The sacrum nutates whenever the body is vertical and increases in sagittal plane motion

48. Sacral Nutation Nutation resisted by interosseus and sacrotuberous ligaments Vleeming and Lee 1997

49. Unlocking ( LPP) of the SIJ Counternutation increases tension in the long dorsal ligament Occurs in supine lying Counternutation of the sacrum tightens the long dorsal ligament Vleeming and Lee 1996

50. Force Closure – muscles Inner Unit Transversus abdominus Multifidus Pelvic floor diaphragm Outer Unit Anterior oblique Posterior oblique Deep longitudinal lateral

51. Inner Unit Pelvic floor and Multifidus work as a force couple to stabilize the sacrum This enhances the ability of the TA to stabilize the spine

55. Inner unit – pelvic floor Levator ani Puborectalis Pubococcygeus Iliococcygeus ischiococcygeus

56. Pubococcygeus Ischiococcygeus Iliococcygeus

57. Pelvic Floor - Function Collective action all 4 parts pulls your tailbone and sacrum forward Isolated contraction ischiococcygeus compresses the SIJ Isolated contraction pubococcygeus compresses the PS

58. Inner unit- Force couples and Force closures Sacral position controlled by multifidus, ilio and ischiococcygeus Pubic symphysis stabilized by pubococcygeus, TA, IO

59. Anterior Oblique System Internal and External oblique Contralateral Adductors Intervening anterior abdominal fascia

60. Posterior Oblique System Ipsilateral Gluteus Maximus Contralateral Latissimus dorsi Thoracodorsal fascia

61. Longitudinal Sling Tibialis anterior Peroneus longus Biceps femoris Sacrotuberous ligament Vleeming and Lee 1997

62. Lateral System Gluteus Medius Gluteus Minimus Contralateral Adductors

63. Stability of the System As a consequence of Form and Force closure the stability of a system (the ability to effectively transfer loads through joints) is dynamic and depends on many factors acting at the moment.

64. Stability of the System Intrinsic Factors Osseous Integrity Articular / Ligamentous integrity Myofascial integrity Neural integrity Extrinsic Factors Gravity

65. Right Hip Flexion Right innominate rotates posteriorly Left rotates Anteriorly Sacrum rotates to the right Right PSIS should drop down relative to the sacrum

66. Clinical Relevance Test helps identify ability to transfer load through two legs Ability to balance on one leg

67. Active SLR Mens et al 1997 Developed to look at load transfer through the pelvis in NWB position Can apply form closure in various locations ( ASIS, PSIS, trochanters) Can assess force closure mechanisms

68. Active SLR Patient Supine Palpate the ASIS of the side being tested Have the patient raise the leg through a SLR Note movement of the pelvis and trunk Add form closure Add resistance through the Anterior oblique system

69. Abdominal bulging

70. Specific Analysis of the Neutral Zone for the SIJ Examines the ability of the SIJ to resist vertical and horizontal translation forces ( shear) that are applied passively in NWB ( Lee 1992,1997, 1999)

71. Specific Analysis of the Neutral Zone for the SIJ Need to find the plane of the joint

72. Specific Analysis of the Neutral Zone for the SIJ Feel from 0° to R1 AP through innominate

73. Specific Analysis of the Neutral Zone for the SIJ Does not assess how much movement but the stiffness value of the system Compare right to left for that patient Test when the force closure mechanism is effective

74. Motor Control is NOT a birthright

75. Richardson et al 1999

76. Exercise Design Initially isometric Co-contraction of deep abds and multifidus Low level tonic contraction Low load to start High repetitions Progress to dynamic functional movements of the trunk

77. The Core and the Lower Extremity

79. Motor Learning Formal motor skill training Perception of the specific contraction Understand the task, what it feels like, instructions, visual cues, different postures/positions, various facilitation and feedback Enhance the patients perception of the deep muscle motor skill Focus on one particular muscle at a time

80. Motor Learning Associative Stage  Automatic Stage “Got the idea”  practice  thousands of repetitions Care with fatigue

81. Motor Learning Exercise Progression Commence co-activation of TA/multifidus Combine with pelvic floor contraction Increase holding time Increase number of contractions Reduce feedback Add diaphragmatic breathing (abdominal wall movement while maintaining a deep muscle contraction) Intermediate steps to encourage air flow: counting, talking

82. Rehabilitation Process Facilitation / Isolation of inner unit Re-educate the control of the inner unit Maintain control of inner unit while training outer unit Functional retraining

83. Lab Exercise program for weak TA/ multifidus in sitting, standing, lifting

85. References Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain Scientific Basis and Clinical Approach Richardson, Jull, Hodges, Hides 1999 The Pelvis Girdle An Approach to the examination and treatment of the lumbo-pelvic –hip region Lee 2004 Post Partum Health for Mothers CD Diane Lee 2001