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Transcript of The Spine
CHP 15 K&C
Prolapsed: nuclear material in vertebral canal
Herniation: Any shape change in nucleus beyond its normal border.
Protrusion: nucleus is still maintained by the outer layers of the annulus and supporting lig structures
Repeated overloading in flexion= annular breakdown
Torsional stresses = annular distortion in post/lat corner opposite the direction of mvmt. Outer annular layers begin to separate from each other
Eventually nuclear material seeps into the annular layers
Repeated fwd bending/lifting=strained annular layers=fissuring of annular layers=nuclear fluid seeps into these areas and swelling occurs with repeated stress.
Healing tries to occur
Disc has poor blood supply
Can happen in a 1 time event OR due to gradual breakdown.
Usually with hyper flexion
nucleus is still capable of imbibing water, but annulus weakens and can’t withstand distortion stresses as well.
Progressive fibrous changes in nucleus
Loses ability to imbibe fluid=decreased water content
Nucleus decreases in size
Nuclear extrusions are rare in older people.
Loss of organization of rings of annulus
Loss of cartilaginous end plates
Degenerative effects on spinal mechanics
Hyper mobility at first
This leads to instability
Most are posterior/lateral
Tissue Fluid stasis
With sustained flexion postures = increased pressure of posterior structures
Creep and fluid transfer occur
Sudden movement into extension does not allow for fluid transfer to occur fast enough resulting in injury.
Disc pathologies and related Dx
Excessive axial loading=vert body fx.
Avoid flexion and axial loading
Herniations, disc pain, inflammatory conditions, tissue fluid stasis
Initially painful with extension
Can be controlled with SLOW progressive extension exercises = these people often avoid surgery.
Pain: due to pressure of swollen disc (discs are largely aneural)
Signs/Symptoms of Disc Lesions
Disc Lesions/ Fluid Stasis
Arise from pressure against nerve roots or spinal cord.
Posterior/post-lat protrusion: Most common
Pt. c/o midline backache into buttock or thigh
Lg. ones = possible bladder or saddle anesthesia
Anterior protrusion: not common
Back pain w/o neurological signs
Most common between L4-5 & L5-S1
20-55 yrs ( more common 30-45)
Associated with bending, lifting, standing up after seated, faulty posture.
Increases with inactivity
Increases with transitional movements
Increases with activities that increase intradiscal pressure.
Usually decreases with walking
Pt. prefers standing/walking to sitting
Lateral shift & decreased lordosis
Fwd. bend is decreased and exacerbates sx.
Extension is limited, but w/repetition=centralize
Correcting lateral shift then extending decs’ pain
NSAIDS by MD are important in Acute phase
Similar to L/S
Faulty fwd head posture
Holds head in guarded side bend away form injured side
Flexion peripheralizes sx
Neck retractions f/b extension may centralize sx.
Possible n. mobility impairments in UE
Traction could relieve sx.
Lumbar spine presentation
Cervical spine presentation
Three joint complex
Pathomechanical relationships of the discs and facets
Progressive bony changes leading to
Osteophytes along facets
Narrowing of intervertebral foramina
Consists of the disc and facet jts.
Disc degeneration =
Decrease H2O content
Decreased disc height
Approximation of vertebral bodies
Intervertebral foramina narrows
Initially, instability is present with swelling, spasm
Pain = decreased jt receptor function & ms. recruitment
Hypomobile in affected joints
Hypermobile in early stages
Facet Jt. Pathology
Any functional activity requiring flexibility or prolonged repetitive trunk motions are aggravating
Repetitive lifting & carrying
Impaired Spinal Extension
Ext. may irritate n. root due to stenosis.
In acute stage: pain with all motions along with muscle guarding
When subacute&chronic: pain experienced with periods of immobility or excessive activity.
Muscle guarding & Pain
Pain with muscle contraction or stretch
Pain with ADL’s (rolling, turning, sitting, sit-stand, standing, walking)
Pathology of Muscle and Soft Tissue Injuries
Remember PROXIMAL before DISTAL
Sub Acute & Chronic stages
Impaired muscle performance
Impaired mobility: may have contractures in muscle and related connective tissue; adhesions
Impaired spinal control & stabilization during functional activities
Impaired postural awareness
Limited ADL’s, work, and recreational activities. (difficulty with repetitive or sustained postures, lifting, pushing, pulling, reaching.)
Injury usually occurs with falls, repeated loading, and twisting
Common Sites for Lumbar Strain
Extension injuries compress post. spine
The neutral zone
A mid-range where no stress is places on passive structures
Controlled by core muscles
Instability = more work by muscles to maintain the neutral zone.
Patients with LBP
Delayed TrA contraction
Atrophy of multifidus
Core training improves outcome in acute, chronic patients.
Focus on Evidence
Along iliac crest
Many forces converge here
Attachment of the lumbodorsal fascia, quadratus, erector spinae, and Iliolumbar ligament.
Usually occur with flexion/extension trauma
Flexion injuries compress anterior spine
More = instability =
Can be due to:
Poor neuro muscular control of core
Altered recruitment pattern
Inhibition from pain
Patients with cervical headaches
Train deep flexors = decrease H/A
Subacute 4-12 weeks
Some ADL’s & repetitive mvmts still = P.
Stages of recovery
Pt. has flexed posture; sometimes lat. Shift too
Ext. tests decrease pain & centralize sx.
Dx may include: disk lesions, fluid stasis.
Present w/ hypermobile segment, poor spinal stability segmental or global
Dx: trauma, lig laxity, spondylolysis, spondylolisthesis
Chronic pain syndrome
> 6 months
Acute 0-4 weeks
Constant pain, no position relieves it
Chronic > 12 weeks
Emphasis is to return pt. to high demand activities
Presents with guarded posture or increased muscle tension.
Dx: strains, tears, contusions, overuse.
Pt. does not like to be upright for ADL’s
Testing movements increases sx.
Traction or other NWB activities decrease sx.
NWB Bias (traction syndrome)
Ext. Bias (Extension Syndrome)
Presents w/ flexed posture which is comfortable
Ext. tests exacerbate sx & cause peripheralization
Dx. Spondylolisthesis, stenosis, ext load injury, swollen facet jts.
Flexion Bias (Flexion Syndrome)
Pts. Present with restricted mobility on 1 or more segments.
Pain and neurological sx
Inability to perform ADL’s
Guarded posture (prefer flexion, extension, or NWB)
Educate the Patient
Self mgmt & inform pt of precautions and anticipated progress
Demonstrate safe postures
Practice positions & mvmts that feel comfortable
Teach awareness of position & mvmt
Cervical & scapular mvmts, pelvic tilts, neutral spine
Decrease acute sx
Modalities, massage, traction, manip, rest.
Teach safe ADL’s
Roll, sit, stand, walk with safe posture. Progress sitting>30; stand > 15 min; Walk > 1mi.
Initiate neuro ms activation & core control
Core techniques: drawing in, multifidus contractions; Basic stabilization
Pain: but only with excessive stress to involved structures
Impaired posture/postural awareness
Impaired NM control; low ms endurance/strength
Cant perform ADLs for extended periods
Poor body mechanics
HEP, Safe movements/postures, Ergonomics
Teach safe body mechanics
Develop NM control, strength, endurance
Progress core stab;Extremity training w/ core trng
Prog awareness & control of spinal alignment
Practice active control in pain free positions with all ex. Lots of posture correction
Increase mobility in tight muscles/jts/fascia
Jt. Mobs, muscle inhibition, self stretches.
Develop cardio endurance
Low/mod aerobic ex. Emphasize spinal bias
Pain only with excessive stress to involved tissue
Poor NM control/endurance with high level act
Flexibility and strength imbalances
Inability to perform high intensity physical demands for extended time
Emphasize spinal control in high intensity act
Practice active spinal control in various act that challenge balance
Emphasize habitual use of techniques of posture correction.
Apply ergo changes to home environment
Effects of bed rest on discs
Imbibement (disc takes on fluid)
Pain upon rising
What happens to someone in prolonged flexed posture.
Avoid these in acute phase of disc lesion
Improve dynamic trunk & extremity strength, coordination, endurance
Progress dynamic core stab emphasizing functional goals
Increase mobility in tight muscle/jt/fascia
Mobs/manip/muscle inhibition/self stretches
Increase cardio endurance
Progress intensity of aerobic ex.
Teach safe progressions to high level act
Emphasize spinal control, endurance, timing, speed in core stabilization. Specificity.
Disk pressure compared to standing
Least when lying supine
Increases by 50% when sitting with hips/knees flx
Doubles if leaning fwd while sitting
Sitting reclined to 120deg. And lumbar support of 5cm = lowest load while sitting