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Week # 5 • MVC client – continued treatment • Lumbar – Pelvis – Hip Complex • Treatment approaches PsychoSocial System Stability Control system Passive system Active system Panjabi 1992 Case • 33 yr old computer , data controller • Complete assessment • Treatment approach Segmental Stabilizing Systemmuscles • Palpation of multifidus • Potential to activate Transversus Abdominis – More cues of pelvic floor to decrease use of IO Muscles of the Core 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% No exercise patient – fusion No change cross- sectional and density decreased Core Kinnections Heather Curilla PT Susan Massitti FCAMT Multifidus contracting = stability Multifidus Activation Lab • Assess ability of the Transversus abdominus to contract • Assess function of multifidus using palpation and motor firing Treatment Approaches • Mobilizations , Manipulations - cautions to mobs end range and manips • Exercise • Education Therapist factors • • • • • • • • Subjective assessment Inadequate information Failure to discuss treatment options Consent Insufficient biomechanical examination Physical limitation Lack of confidence Equipment • Incompetence Patient factors • • • • • • • • • Lack of consent Mental status Obsession with manipulation Inability to communicate Unable to relax Pain Intoxicated/heavily medicate Inappropriate end feel Instability Bony elements • Fractures – presently healing • Dislocations presently healing Bony elements • Active infection – osteomyelitis, tuberculosis • Congenital anomalies • Gross foraminal or spinal canal encroachment on x-ray Neurological • Extra segmental pain increase with passive neck flexion • Bilateral or quadrilateral multisegmental paraesthesia • Hyperreflexia • +babinski, oppenheimer, hoffman • Clonus • Ataxia • Neurological spasticity Neurological • Bladder and bowel dysfunction • Nystagmus • Dysphagia/dyshasia • Wallenberg’s syndrome ( PICA) • Other cranial nerve S/S Spinal cord disease/injury • Extrasegmental pain BELOW level of lesion with PNF • Bilateral , quadrilateral parasthesia, weakness, spasm hyperreflexia hyporeflexia below level of lesion • Ataxia Vascular considerations • Vertebral artery • Vascular disease • Bleeding disorders • Aortic graft Soft tissue • Collagen diseases – – – – – Ehler’s –Danlos Syndrome Marfan’s Syndrome Osteogenasis imperfecta Achondroplasia Benign Hypermobility ( Caution) Age • Elderly – tissue health • Children – consent , skeletal maturity Metabolic Disease • Bone Disease • Osteoporosis • Paget”s Systemic Disease /Condition • Diabetes ( caution) • Endocrine disorders ( caution) • Haemophilia • Pregnancy Inflammatory Diseases • • • • • Active inflammatory disease Rheumatoid Arthritis Ankylosing Spondylitis Psoariatic Arthritis Reiter’s Inactive inflammatory Disease ( caution) Medication • Anticoagulants • Any med that effects collagen eg corticosteriods, tamoxifen • Med linked to osteoporosis • Anti-depressants ( caution) References • Greenspan, A., Orthopedic Radiology, Lippincott Williams & Wilkins, philadelphia, 2000, 3rd edition • Daffner, R., Clinical Radiology, 2nd edition, Lippincott Williams & Wilkins, 1999 • Grieve, G., Modern manual therapy, 2nd 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 Treatment Options • Mobilization, manipulation • Exercise Rehab • Muscle Retraining • Education Lumbar Traction sustained vs oscillations Unilateral Flexion Lab • Demo of Flexion gap manipulation • Demo and practice sustained traction, graded flexion with muscle activation Pelvis • When to look further • Some assessment tools 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. Transmission of Force 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. 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 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 What can affect the neutral zone? 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 Force Closure – Ligaments • Several strong ligaments connect the innominate and sacrum • Ligament tension varies with sacral/innominate position Long Dorsal Lig 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 Sacral Nutation Nutation resisted by interosseus and sacrotuberous ligaments Vleeming and Lee 1997 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 Force Closure – muscles • • • • • Inner Unit Transversus abdominus Multifidus Pelvic floor diaphragm • • • • • Outer Unit Anterior oblique Posterior oblique Deep longitudinal lateral 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 Inner unit – pelvic floor Levator ani Puborectalis Pubococcygeus Iliococcygeus ischiococcygeus Ischiococcygeus Iliococcygeus Pubococcygeus 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 Inner unit- Force couples and Force closures • Sacral position controlled by multifidus, ilio and ischiococcygeus • Pubic symphysis stabilized by pubococcygeus , TA, IO Anterior Oblique System • Internal and External oblique • Contralateral Adductors • Intervening anterior abdominal fascia Posterior Oblique System • Ipsilateral Gluteus Maximus • Contralateral Latissimus dorsi • Thoracodorsal fascia Longitudinal Sling • • • • Tibialis anterior Peroneus longus Biceps femoris Sacrotuberous ligament • Vleeming and Lee 1997 Lateral System • Gluteus Medius • Gluteus Minimus • Contralateral Adductors 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. Stability of the System Intrinsic Factors Extrinsic Factors • Osseous Integrity • Articular / Ligamentous integrity • Myofascial integrity • Neural integrity • Gravity Right Hip Flexion • • • • Right innominate rotates posteriorly Left rotates Anteriorly Sacrum rotates to the right Right PSIS should drop down relative to the sacrum Clinical Relevance • Test helps identify ability to transfer load through two legs • Ability to balance on one leg 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 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 Abdominal bulging 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) Specific Analysis of the Neutral Zone for the SIJ • Need to find the plane of the joint Specific Analysis of the Neutral Zone for the SIJ AP through innominate Feel from 0° to R1 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 Motor Control is NOT a birthright Richardson et al 1999 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 The Core and the Lower Extremity 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 Motor Learning Associative Stage Automatic Stage • “Got the idea” practice thousands of repetitions • Care with fatigue 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 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 Lab • Exercise program for weak TA/ multifidus in sitting, standing, lifting 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