1. PTA 130 Fundamentals of Treatment I
Spine and Sacroiliac

2. 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

3. Spine and Sacroiliac

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

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

7. 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

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

9. 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

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

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

12. 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

13. 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.

14. 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

15. Intervertebral Disc
K&C pg 409 fig 15.3

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

17. 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.

19. 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.

20. 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

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

22. 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

23. 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.

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

26. 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

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

29. 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)

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

32. 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

35. Prolonged Side-Bending Stretch

36. 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

37. 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

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

39. 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.

40. 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

41. 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

42. 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

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

44. Spinal Fusion
Harrington rods
Bone graft
Cage
Bone Graft

45. Spinal Fusion
Anterior approach
Cage
Anterior Approach

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

47. Spinal Surgery
Catalog.nucleusinc.com
Kyphoplasty

48. 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

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

50. Post-Operative Exercise
Glut Sets
Heel Slides
Gentle abdominal sets

51. 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

52. 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

53. Spinal Orthotics

54. LUMBOSACRAL CORSET

55. CERVICAL ORTHOSES/COLLARS
Soft Collar
Philadelphia Collar

56. Cervical Halo
Non invasive and invasive brace

57. TLSO

58. 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.

59. 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

60. Therapeutic Interventions for Spinal Disorders

61. 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

62. 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

63. Curl-Ups

64. Posterior Pelvic Tilt

65. Single Knee to Chest (SKTC)

66. Double Knee to Chest (DKTC)

67. 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

68. 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

69. Prone Lying

70. Prone Press-Ups

71. Progressive Extension

72. Standing Extension

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

74. 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

75. “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

76. 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

77. Cervical Stabilization
K&C pg 453 fig 16.18

78. Spine Stabilization With Arms

79. Spine Stabilization With Unsupported Arms and Legs

80. Quadruped Arm Raise

81. Quadruped Arm and Leg Raise

82. Posterior Pelvic Tilt

83. Bridging Progression

84. 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

86. Tennis Ball Self Release Technique

88. Sacroiliac Joint

89. Sacroiliac Joint

90. 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

91. 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

92. QUESTIONS?