Transcript Spine Biomechanics

Treatment Based Classification
of the Lumbar Spine
Finding Common Ground
• Classification Systems
– Reliable
– Guide Interventions
• Treatment Techniques
– Effective
– Generalizable
Delitto, Erhard, Bowling, Fritz
• Early Establishment of Classification
Scheme for the Low Back
• Case Series
• Randomized controlled clinical trials
• Better Than Standard Treatment?
First Level of Classification
• Treat by Rehabilitation Specialist
Independently
• Referral to Another Healthcare Practitioner
• Managed by Therapist in Consultation with
Another Health Care Practitioner
Immediate Care of the Injured
Spine
• Physician Evaluation
• Early Care
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Rest/Activity
Ice/Heat
Modalities for Pain Control
X-ray
Medications
1-2 Weeks and No Change
• Life Impact
– ADL’s
– Sport Specific
Importance of History
• Establish a pattern
– What brings on symptoms?
– What relieves symptoms?
• Type of symptoms present
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Sharp, stabbing
Dull, aching
Stretching
Pinching
Importance of History
• Intensity of Symptoms
– Pain levels
• Location of Symptoms
– Rule in/out potential causes
– Add focus to your evaluation
Neurological Examination
• Indication - Symptoms Below the Buttock
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LE Sensory Testing
Muscle Strength Assessment
Reflex Testing
Nerve Root Testing
Babinski testing
Clonus
Pelvic Assessment Results
• 3 of 4 Tests Composite
– Reliability k=.88
• If (+) SIJ Manipulation Indicated
– Manual Techniques
– Manipulation
• If (-) Palpate Iliac Crest Heights
– Correct difference with heel lift
Movement Testing Results
• Symptoms worsen: Paresthesia is produced
or the pain moves distally from the spine
– Peripheralizes
• Symptoms improve: Paresthesia or pain is
abolished or moves toward the spine
– Centralizes
• Status quo: Symptoms may increase or
decrease in intensity, but no centralize or
peripheralize
Movement Testing
• Assess for a Lumbar Shift
– Pelvic translocations PRN
• Single Motion Testing
• Repeated Motion Testing
• Alternate Positioning (if needed)
Postural Observation
• Presence of a Lumbar
Shift
– Named by the shoulder
Pelvic Translocation
• Performed Bilaterally
– Assess Symptom
response
– Worsen
– Improve
– Status Quo
Lumbar Sidebending
• Determine
Capsular/NonCapuslar
• Perform Movements
– Pelvic Translocation
– Flexion
– Extension
• Status
– Worsen
– Improve
– Status Quo
Pelvic Translocation
• Assess Status
– Worsen
– Improve
– Status Quo
Flexion
• Assess Status
– Worsen
– Improve
– Status Quo
• Note ROM limits
• Quality of Motion
Extension
• Assess Status
– Worsen
– Improve
– Status Quo
• Note ROM limits
• Quality of Motion
Sidebending/Worsen
• Symmetrical Sidebending
– Cyriax Capsular Pattern
• Do Repeated Motions Worsen
– Traction Syndrome
– If Extension worsens begin in flexion
– If Flexion worsens begin in extension
Sidebending/Worsen
• Asymmetrical Sidebending
– Cyriax Non Capsular Pattern
• Do Repeated Motions Worsen
– Traction Syndrome
Sidebending/Improve
• Symmetrical (Capsular)
• Do Repeated Motions Improve?
– Flexion Syndrome
• ACTIVE FLEXION
– Extension Syndrome
• ACTIVE EXTENSION
Sidebending/Improve
• Asymmetrical (Non Capsular)
• Do Repeated Motions Improve?
– Lateral Shift Syndrome
• Active Pelvic Translocation
Sidebending/Status Quo
• Symmetrical (Capsular)
• Mobilization Syndrome
– Passive Flexion General
– Passive Extension General
Sidebending/Status Quo
• Asymmetrical (Non capsular)
• No Pattern
– General Mobilization
• Specific Pattern
– Specific Mobilization
Opening Restriction
• Forward Flexion
– Deviation to the side of the Restriction
• Sidebending
– Limitation to the contralateral side
• Combined Flexion and Contralateral SB’ing
Maximal Opening
• Flexion Mobilizations
• Flex LE to desired
levels
• Posterior Glide of LE
on segments
Opening Mobilization
• Flex to desired level
• Lift Bilateral LE to
ceiling to gap/open
• Opening on side on
table
• Progression - Laterally
flex table
Closing Restriction
• Extension
– Deviation to contralateral side
• Sidebending
– Limitation to the ipsilateral side
• Combined Extension and Ipsilateral SB’ing
Maximal Closing
• PA Glides
• Begin in Neutral
• Progress to Extended
Position
Self Mobilizations
• Force Movement at
Specific Levels
• Modified Press Up
Exercise
• Extension at L3
• Towel Roll to flex at
L4/5
Opening/Closing Manipulation
• Flex to level of
involvement (Gap
L4/5 to manipulate
L4)
• Stabilize LE
Opening/Closing Manipulation
• Maximally Rotate
Upper Body to end
range
• Have Patient Exhale
and relax abdominals
• Overpress gently with
upper body rotation
• Opens side toward
ceiling/Closes opp.
Maximize Gains with Home
Programs
• Home Exercise of
Towel Sitting
• Open- Contralateral
• Close- Ipsilateral
Worsen/Improve
Neurological Examination
• Indication - Symptoms Below the Knee
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LE Sensory Testing
Muscle Strength Assessment
Reflex Testing
Nerve Root Testing
Babinski testing
Clonus
Movement Testing Results
• Symptoms worsen: Paresthesia is
produced or the pain moves distally
from the spine
– Peripheralizes
• Symptoms improve: Paresthesia or
pain is abolished or moves toward the
spine
– Centralizes
Peripheralize/Centralize
• Classic Disc
• Stenosis
• Spondylo..
Postural Observation
• Presence of a Lumbar
Shift
– Named by the shoulder
Sidebending/Improve
• Asymmetrical (Non Capsular)
• Do Repeated Motions Improve?
– Lateral Shift Syndrome
• Active Pelvic Translocation
Manual Shift Correction
• Manual Shift
Correction by PT
• Slow Correction
• Slow Ease of Release
Postural Corrections
• Self Correction
• Positioning for
Electrical Stimulation
Self Shift Corrections
• Performed every 30
minutes
Sidebending/Worsen
• Symmetrical Sidebending
– Cyriax Capsular Pattern
• Do Repeated Motions Worsen
– Traction Syndrome
– If Extension worsens begin in flexion
– If Flexion worsens begin in extension
Flexion Worsens
• Prone Traction
Extension Worsens
• Supine Traction
Sidebending/Worsen
• Asymmetrical Sidebending
– Cyriax Non Capsular Pattern
• Do Repeated Motions Worsen
– Traction Syndrome
Sidebending/Improve
• Symmetrical (Capsular)
• Do Repeated Motions Improve?
– Flexion Syndrome
• ACTIVE FLEXION
– Extension Syndrome
• ACTIVE EXTENSION
Centralization Phenomenon
• Intensity will increase as pain centralizes
• Once no radicular symptoms ~2wks left
• Must re-introduce provocative motion once
radicular symptoms are resolved
Improve with Extension
• CASH Brace
• Worn 24hrs
• Wean Slowly
Improve with Extension
• Prone Press Ups
Self Correction for Extension
• Repeated Extension in
Standing
• Performed every 30
minutes
Posterior/Anterior Glides
• Assessment
• Symptom Provocation
• Treatment
Flexion Improves
• Flexion Exercise
Flexion Improves
• Flexion Postures
Flexion Mobilizations
• SNAGs with Belt
Status Quo
Sidebending/Status Quo
• Symmetrical (Capsular)
• Mobilization Syndrome
– Passive Flexion General
– Passive Extension General
General Flexion
• Flexion Mobilizations
• Flex LE to desired
levels
• Posterior Glide of LE
on segments
General Flexion for Home
• Slouched sitting
• Flexion stretches
• Flexion activity
– Rower
– Bike
General Extension
• PA Glides
• Begin in Neutral
• Progress to Extended
Position
General Extension for Home
• Force Movement at
Specific Levels
• Modified Press Up
Exercise
• Extension at L3
• Towel Roll to flex at
L4/5
Sidebending/Status Quo
• Asymmetrical (Non capsular)
• No Pattern
– General Mobilization
• Specific Pattern
– Specific Mobilization
Opening Restriction
• Forward Flexion
– Deviation to the side of the Restriction
• Sidebending
– Limitation to the contralateral side
• Combined Flexion and Contralateral SB’ing
Opening Mobilization
• Flex to desired level
• Lift Bilateral LE to
ceiling to gap/open
• Opening on side on
table
• Progression - Laterally
flex table
Opening Mobilization
• Joint Glide in Flexion
• Look for deviation
with forward flexion
to determine where in
range to mobilize
Closing Restriction
• Extension
– Deviation to contralateral side
• Sidebending
– Limitation to the ipsilateral side
• Combined Extension and Ipsilateral SB’ing
Closing Mobilizations
• PA’s with unilateral
support
• SNAG’s in Extension
Opening/Closing Manipulation
• Flex to level of
involvement (Gap
L4/5 to manipulate
L4)
• Stabilize LE
Opening/Closing Manipulation
• Maximally Rotate
Upper Body to end
range
• Have Patient Exhale
and relax abdominals
• Overpress gently with
upper body rotation
• Closes side toward
ceiling/Opens opp.
Maximize Gains with Home
Programs
• Home Exercise of
Towel Sitting
• Open- Contralateral
• Close- Ipsilateral
General Stabilization
• Pelvic Neutral with
leg lowering
General Stabilization
• Side Lift
– Quadratus
– Obliques
– Minimal LB stress
Adhered Nerve Root
• Status Quo
• Reproduce Radicular
Symptoms with
Opening
Case 1
• 18 year old soccer player
• 6wk history of LBP
• Played until 1 week ago then too painful to
overcome
• Dull aching right sided low back pain
– Denies pain in any other location
Case 1 Soccer Player
• Pain is 0-7/10
• Pain with Activity
– shooting ball
– cutting back and forth
– right sidebending
• Pain improves
– Rest
– Ice
– Relafen
Case 1 Soccer Player
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3 of 4 SIJ tests (-)
50% reduction in Right Sidebending
Good Forward Bending
50% reduction in Left Rotation
Extension is 50% limited
• Quadrant Test or Max ? Test is +
Hypothesis
• What is wrong with this player?
• What group does he belong in?
Hypothesis
• Status Quo
• Closing Restriction
• Specific Mobilization
• How would you treat him?
• How long will it take?
Case 1 Soccer Player Outcome
• Performed manipulation on first treatment
– Greater than 50% improvement in range
– Joint mobilizations for closing
– Home program
• Facet joint closing with towel under right buttock
• Prone press ups at home
Case 1 Soccer Player Outcome
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Next Treatment
60% improvement in pain and range
Continued with closing mobilizations
4th treatment return to full 100% painfree
play
Acute Lumbar Treatment
• Diagnosis Can Lead Intervention
• Classification Dictates Treatment
• Maximize Treatment Goals; In Clinic,
Home, and Return to Work