PTA 130Fundamentals of Treatment ISpine and Sacroiliac

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

Spine and Sacroiliac

Review Anatomy of the Spine

Vertebral Column

•33 vertebrae▫7 cervical▫12 thoracic▫5 lumbar▫5 sacral▫4 coccygeal

Spinal Curves

•Primary curve▫Kyphosis: “C” curve▫Convex posterior▫Thoracic and sacral regions

•Secondary curve▫Lordosis▫Convex anteriorly▫Cervical and lumbar regions

Spinal Segment

•Motions of the Spinal Column

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

Curves Function Dynamically

•Extension: lordosis / kyphosis

•Flexion: lordosis / kyphosis

Common Spinal Pathologies

•Herniated Disk•Sciatica•Spinal Stenosis•Degenerative Disk Disease•Compression Fracture•Scoliosis•Spondylolisthesis•Ankylosing Spondylitis

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

Intervertebral Disk•Annulus Fibrosus-

▫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.

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

Intervertebral Disc

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

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.

Herniated DiskThe 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.

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

Herniated Disk

•Treatment▫Modalities for pain control▫Soft tissue mobilization▫Joint Specific treatment▫Disc Specific treatment▫Mechanical traction▫Core strengthening exercises▫Stretching exercises

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

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.

Spinal Stenosis (cont’d)

•Treatment: ▫Positional stretches▫Core stabilization exercises▫Modalities▫Soft tissue mobilization

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

Degenerative Disc Disease

•Treatment: ▫Disc specific treatment▫Joint specific treatment▫Core stabilization▫Stretching▫Modalities▫Posture re-education▫Instruction in proper ergonomics

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)

Compression Fracture (cont’d)

•Treatment: ▫Immobilization (acute phase)▫Core stabilization exercises▫Posture re-education▫Modalities▫Medication (osteoporosis)▫Surgery

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

Prolonged Side-Bending Stretch

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

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

•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.

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.

Spinal Pathologies

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

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

Common Spine Surgical Interventions

•Spinal Fusion▫Indications

Instability Severe DDD Spondylolisthesis Fractured vertebra Chronic pain

▫Precautions- immobilization during protection phase

Spinal Fusion

Bone Graft

Cage Anterior Approach

Spinal Fusion

Lumbar DiscectomyLumbar Laminectomy

Spinal Surgery

Kyphoplasty

Spinal Surgery

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

Post-Operative Exercise

•Generally early ambulation▫Occasionally patient will be on bed rest for

a few days

•Bed Exercise▫Ankle pumps

▫Quad sets

Post-Operative Exercise

•Glut Sets

•Heel Slides

•Gentle abdominal sets

•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

Principles of Spine Disorder Management

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

Spinal Orthotics

LUMBOSACRAL CORSET

CERVICAL ORTHOSES/COLLARS

Soft Collar Philadelphia Collar

Cervical Halo

TLSO

Scoliosis: Milwaukee Orthosis

Scoliosis: Boston Brace

Therapeutic Interventions for Spinal Disorders

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

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

Curl-Ups

Posterior Pelvic Tilt

Single Knee to Chest (SKTC)

Double Knee to Chest (DKTC)

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

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

Prone Lying

Prone Press-Ups

Progressive Extension

Standing Extension

Lumbar Stabilization

•What key muscle groups need to activate in order to provide optimal stabilization to the lumbar spine? ▫Transverse abdominis

▫Multifidus muscles

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

“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

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

Cervical Stabilization

Spine Stabilization With Arms

Spine Stabilization WithUnsupported Arms and Legs

Quadruped Arm Raise

Quadruped Arm and Leg Raise

Posterior Pelvic Tilt

Bridging Progression

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

Tennis Ball Self Release Technique

Sacroiliac Joint

Sacroiliac Joint

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

Spinal Pathologies• SIJ Dysfunction

▫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

QUESTIONS?