Copy of Improved Activation of Lumbar Multifidus FollowingSpinal Ma

RESULTS & DISCUSSION

DISCUSSION

RESULTS

NEUROPHYSIOLOGIC EFFECT OF SPINAL MANIPULATION

BIOLOGIC POTENTIAL OF SPINAL MANIPULATION

• Increased thickness, therefore increased muscle activation

• Biomechanical changes
• neurophysiologic or reflexogenic changes
• neuroendocrine changes
• circulatory changes
• immune system changes

• Dramatic change in activating the multifidus during prone upper extremity task immediately following the spinal manipulation
• Use of RUSI – possible neurophysiologic effects of multifidus muscle after spinal manipulation

• Affects the sensory information to the CNS
• Reduces sensory information from receptive nerve endings in the innervated paraspinal tissue
• Influences mechanism which produces pain
• Increase in pain tolerance and or pain threshold

FINDINGS

REFLEXOGENIC EFFECT OF SPINAL MANIPULATION

REFLEXOGENIC EFFECT ON THE CASE STUDY

NEUROPHYSIOLOGIC EFFECT ON THIS CASE STUDY

• Increase in the ability to thicken the muscle associated with increase muscle activation
• Thickness could be secondary to force applied by the surrounding musculature

• Spinal manipulation = Paraspinal Muscle Reflex
• Affects central or peripheral pathways
• Increase or decrease the excitability of the motor neurons

• Alters motor neuron pool excitability -> affects muscle
• HVLA thrust -> activates mechanoreceptors and proprioreceptors -> alters afferent input -> changes motor neuron excitability -> muscular changes around the manipulated area

• Pain was not the chief complaint (minimal complain)
• Not considered to be an explanation of the increased muscle activation observed

LIMITATIONS IN THIS STUDY

MANIPULATION

FINDINGS

• Cavitations did not occur at the targeted area:
• 1st manipulation = cavitation occured caudal to targeted area
• 2nd manipulation = occured higher on the lumbar spine

• Improved motor control following manipulation helped during the lifting task
• Manipulation has an initial influence -> need long term rehabilitation goals

• Results were observed for a short-term period
• Doesn't show if spinal manipulation maintains motor activation for longer periods
• Further research needed to see if spinal manipulation has a long-term rehabilitative effect

TREATMENT & REHABILITATION

HISTORY

TREATMENT

FIRST SPINAL MANIPULATION

SECOND SPINAL MANIPULATION

• 2nd manipulation: local manipulation
• Right side-lying + left hip flexed until motion palpated at L4-L5 + patient torso rotated left until motion is palpated at L4-L5 + HVLA rotational thrust of pelvis in ant.- inf direction

• 1st manipulation= regional lumbar pelvic manipulation
• Why? greater effect on the lower lumbar and sacral regions
• Supine + left side bending with right rotation of torso + Patient rotated towards the therapist + HVLA thrust at ASIS in ant.-post. direction

• Patient’s Complaints: stiffness at the lower lumbar levels
• Result before Treatment = Poor activation of the lumbar multifidus (observed with RUSI)
• Goal: activate the lumbar multifidus muscle
• Treatment = spinal manipulation

SYMPTOMS

PATIENT

• 33 year old male
• 21 years history of Lower Back Pain since the age of 12
• No MOI: Insidious Onset
• P is debilitating

• Initially accompanied by L post thigh P radiating towards the ankle
• Spontaneous resolution of leg pain 6 months after onset
• Presently, LBP is recurrent with occasional L ant thigh numbness 2x/year

OUTCOMES AFTER MANIPULATION TECHNIQUE

FOLLOWING SPINAL MANIPULATION

Improved Activation of Lumbar Multifidus Following Spinal Manipulation:

• Patient was sent home
• No home exercise
• Instructed to remain active

• Change in multifidus thickness during rest
• Improved thickness and improved contraction of multifidus muscle during upper extremity lifting task
• Patient said the lifting task was easier to perform
• Primary complaint of stiffness = resolved

A Case Report Applying Rehabilitative Ultrasound Imaging

ALEXANDER K. BRENNER et al. (2007) Journal of Orthopaedic and Sport Physical Therapy. Volume 37 (10).

ASSESSMENT

Presented

by Bea, Luxi and Shogofa

FUNCTIONAL TESTING

INITIAL EVALUATION

PALPATION AND OBSERVATION

• Pain free Primary Complaint = Stiffness
• Mild decrease in Lumbar Lordosis on Standing
• Central post to ant spring testing over L4-L5 spinous processes - Lumbar Hypomobility

• Prone Position
• Unilateral UE elevation/lifting task to activate contralateral lumbar paraspinal muscles
• Difficulty completing the task
• Increased P in lumbar region

• Lateral to spinous processes of L4-L5 and Medial to longisimuss muscles
• Decreased muscle activation on L paraspinal muscles around L4-L5 compared to the R

ULTRASOUND

FABQ - W

• Fear Avoidance Behavior Questionnaire Work Subscale
• 3/4 Clinical Predictors for Short Term Success with Regional Lumbopelvic Manipulation

• R=0.79 correlation
• Muscle Thickness Change VS Muscle Activation (EMG)
• 3 measurement times (at rest and after lifting task)
• 1) PRE 2) POST 3) 24 hours POST
• Poor activation: < 22% muscle thickness change (control)

• Sonosite 180 plus (60mm, 5MHz)
• Muscle recruitment measurement during a prone UE lifting task - Multifidus Thickness Change
• Objective Measurement not based on volition of deep muscle contraction

OUR MODALITY APPLICATION

BENEFITS

Duty Cycle

ELECTRICAL STIMULATION

Stimulation of motor

• 10 sec on + 50 sec off (to begin)
• 10 sec on + 30 sec off (further in the rehab process)

150 us pulse width

Pad Placement

• 1 pad on anterolateral transverse abdominis + 1 pad on multifidus muscle (L4-S1)

• Aim: decrease stiffness in the multifidus muscle
• Execution: Neuromuscular Electrical Stimulation (NMES)

Carrier Frequency

• Contraction of multifidus
• Reduce stiffness and re-education of the muscle
• Stabilize the pelvis by contracting the transverse abodminis and multifidus muscles

Should be set by the machine

(2500Hz - 5000 Hz)

Contraction

• Turn up intensity until visible muscle contraction
• Ramp: 2 sec up + 1 sec down
• Patient will be performing a contraction during the stimulation (upper extremity task, double leg bridge)

Pulse Rate

60 pps

Time

20 minutes

Parameters

PICTURE TAKEN FROM GOOGLE

CONCLUSION

INTERESTINGLY ...

• RUSI offers unique imaging modality to investigate in vivo changes
• Similarly other researches showed improvements for muscles activation immediately after spinal manipulation
• Multifidus activation maintained almost over 24 hours – Big deal!

• Chronic LBP, lumbar stiffness, and difficulty in activating the lumbar multifidus
• Increase in ability to activate multifidus at the level of L4-L5 and L5-S1 immediately post manipulation and maintained for 24h
• Strong suggestion – spinal manipulation may influence multifidus function