Download Ther Ex II Final Dynamic Spinal Stability It is segmental control of

Ther Ex II Final
Dynamic Spinal Stability
 It is segmental control of each spinal segment, making the whole column
stable
 Ability to control the position and motion of the trunk for production and
control of motion in the extremities. PROXIMAL STABILTY for DISTAL
MOTION
 Instability- loss of control of trunk position and motion
 Hx: yoga, pilates, janda (cross syndromes), abdominal hollowing, instability,
endurance & control vs strength
 Why do we want stability?
o Decreases chance of injury or re-injury (segmental and global)
o Controls the motion segment- disc, ligaments, joints, bone, muscles,
extremities
o Maximize UE, LE function  power, precision
o Less recurrence of LBP
o Lower CSA of lumbar multifidus= higher incidence of quad, hamstring,
adductor injury
o Sports hernia- may be assoc. with decreased abdominal to adductor
strength ratio
 Structural instability: Things we don’t really control- fx, bone, alignment
 Dynamic/Clinical/Functional Instability: lack of segmental control strength
deficits, endurance deficits, harmful movement patterns, repetitive or
sustained movements and postures
 3 subsystems in spinal stability (Panjabi)
o Passive- osseous and ligamentous structures
o Active- Musculotendinous system
o Control- Neural NM control of systems (we control active and control)
 Passive Stabilizers
o Vertebra, IVD, Ligaments, Zygoapophyseal joints, ribcage,
thoracolumbar fascia
 Indicators of involvemento Translation on F/E radiographs, spondylolisthesis, traction spirs
(mean extra movement- ligaments (ALL) move too much and tug),
high intensity zones on discs on MRI, facet gapping >1mm on twist CT
scans, moderate to severe DDD on MRI, hypermobility with segmental
manual testing
 Spine can only take 4-5 lbs before it will buckle- mms imperative
 2 mechanisms for increased spinal stability
o Direct movement production and control segmental and global
o Increased intra abdominal pressure (IAP)= increased stability of
spine, not valsalva
 Deep abdominal muscle- compresses abdominal contents increased intraabdominal pressure
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Clinical significance: 40% less compression on discs with TA contration, lbp
correlates to delayed onset of TrA, retraining TA is important for tx LBP,
contraction of IAO and TrA increase intrabdominal pressure and stiffness of
the spine, attachment to thoracolumbar fascia= corset like ring around spine
Thoracolumbar fascia: dynamic- IO and TA fuse posteriorly continuous with
TLF, contraction pulls it taut. MMS don’t go directly to spine but TLF does
Segmental muscles- needed for segmental control
Multifidus- balances flexor moment
Clinical Significance: consistent back pain, the mm function doesn’t come
back right away when the pain is gone. Those with back pain have delayed
onset of TrA and multifidi
Diaphragm: interdigitates with TA, facilitates TA and increased
intrabdominal pressure. We activate before movements
Pelvic Floor: necessary to provide support during increased IAP
Local and deepest muscles
o TA, IO, Multifidi, Pelvic floor, diaphragm, interspinales,
intertransverse, rotatores, deep posterior fibers psoas, medial fibers,
QL (lateral stability.
Core mms- tonic/postural- slow-twitch endurance, contract slowly, fatigue
resistance, train for endurance.
Superficial back mms- lats, RA, EO, ES decreased endurance
Sprain: ligamentous weakness- single or repeated strains, poor postures
Boney pathology: spondylolisthesis; facet arthropathy
These two can lead to passive instability
Disc dysfunction- sprain, tear, degen, herniated, prolapse passive
instability
LBP
o Arthrogenic muscle inhibition- any damage to joint- altered mm
activation
o Reflex muscle inhibition- more to do with pain, pain will create
feedback creating altered mm action around the joint
o CLINICAL SIGNIFICANCE: DYNAMIC structures not functioning to
produce and control movements of the spine
Symptom of spinal instability: episodic LBP, back gives out, hx of trauma,
relieved temporarily with manipulation, catch with return to stand, pain and
stiffness with prolonged position, pain with transitional movements
Exam findings: aberrant movement with ROM testing, instbality catch with
movement testing, increased mm tone in relaxed standing, step deformity
(spondylo), hypermobility, positive dynamic instability tests
Dynamic stability test- vertical compression, prone active instability test,
prone (passive) lumbar extension test, endurance (Sorenson, mcgill, leg and
chest raise tests, prone and supine), sahrmann core stability test, lumbar
protective mechanisms
Where’s the evidence? Clinical prediction rule- patients ag less than 40 years
old, SLR greater than 90 positive prone active instability test, aberrant
motion with AROM testing, # of previous episodes, frequency increasing,
hypermobility
 Training goals- train so body recognizes it needs to fire to control, make
movements automatic, train functionally, repetition and ENDURANCE
 Precautions with exercise- psychological distress, neurological symtoms
(disc protrusions, stenosis), pain patterns
 Alignment first, Happy place base of support, retrain
Posture
 Plumb line- surface landmarks
o Ear lobe
o Shoulder joint
o Midway of trunk
o Greater trochanter
o Sl. Ant. To knee
o Sl. Ant. To ankle
o Shifted forward= Achilles tendonitis, plantar fascia
 Lordotic
o Increased Lumbar lordosis, anterior pelvic tilt, knee hyperextended,
abdominals/hamstrings stretched, tight erectors and hip flexors
 Flat back
o Head forward, c spine extended, tspine- upper increased flexion,
lower straight, lspine flexed, pelvis posterior tilt, hip extended,
knees extended. Weak hip flexors, tight/strong hamstrings,
abdominals
 Sway back posture
o Head forward, cspine- extended, tspine- increased flexion, posterior
displacement of upper trunk, lspine flattened, posterior pelvic tilt,
hyperextended hips, hyper extended knees, weak hip flexors,
external obliques, upper back extensors, neck flexors,
tight/strong- hamstrings internal obliques. Strong/not short: LB
mms. Bold means difference between flat back and sway back
 Kyphotic Posture
o Forward head, neck hyperextended, rounded shoulders, increase
thoracic kyphosis, increase lumbar lordosis, anterior pelvic tilt, knees
hyperextended, weak upper back muscles, hamstrings, tight hip
flexors and erectors
 SLIDE 19
 Desk Job posture- forward head with rounded shoulders, posterior neck
muscles overworked, narrowing IVF, weakened upper back muscles
 Affects us?
o Makes you look old, limits ROM, increases pain or discomfort, pain in
jaw, decreased efficiency of the lungs, LBP, nerve problems, inhibit
elimination of waste.
o Double crush- issue with nerve  loose blood flow and then have
more issues
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S/S
o Long-standing c/o pain, gradual increase in pain over time, insidious
onset, length of time for aggravation decreased, difficulty finding
comfortable position, recreational activities hindered (load joints
when shortened)
Progression of symptoms
o Muscle fatigue from exertion trying to keep proper alignment, mms
and ligaments become tight and may have lasting change in
extensibility, joint mobility may become adaptively restricted. Stiff,
painful, and OA
Assessment
o Alignment- lateral, anterior, posterior (may need mob first), may not
fall into a category, body has adapted. Get moving and then
strengthen in new range
o ROM, joint mobility, flexibility- what can they do, what can they
tolerate, impairments contributing to posture
o MM strength and endurance- tight and strong, weak and long,
postural mms are endurance mms
JANDA Crossed Syndromes (STAR)
o Upper crossed
 Deep cervical flexors and lower trap/serratus ant. Inhibited
 Upper trap/levator/scom/pecs facilitated
o Lower crossed
 Abdominals, glute min/med/max inhibited
 thoraco-lumbar extensors, rectus femoris/iliopsoas facilitated
JANDA layered syndrome
o mms which tend to inhibition- lower stabilizers of scapulae, shoulder
girdle ER, lumbosacral, ES, glute max, intrinsics
o Mms which tend to tightness- cervical erector spinae, upper trapezius
levator scapulae, thoracolumbar erector spinae, hamstrings, gastroc
soleus
Body Types
o Ectomorph (tall and skinny) more likely to have laxity
o Mesomorph- shoulders broader than hips= tight
o Endomorph (shoulders same as hips
Postural syndrome from McKenzie
o Caused by mechanical deformation of soft tissues or vascular
insufficiency arising from prolonged positional or postural stresses
affecting articular structures
o Local pain, intermittent, no movement loss, no effect with dynamic
movement testing, symptoms reproduced with sustained end range
positioning
Stages of rehab
o Acute: 0-4 wks. Control symptoms, protect
o Subacute: 4-12 wks. Basic training, controlled motion, dynamic stab.
o Chronic: >12 weeks. Postural re-ed, ergonomic assessment
 Keys to rehabo Pt education, feedback, healthy living, maintenance
 Body awareness- more compression with slouched posture-42 lbs vs 12 lbs
 Pt awareness- verbal reinforcement, visual reinforcement, tactile
 Substitutiono Neck extension vs chin tuck. Extension- shear in extension
o Shoulder elevation vs scapular retraction (tuck shoulder blades in
back pockets)
o Increased lumbar lordosis vs abdominal contractions- use
contraction
 Desk job dysfunction- forward head, rounded shoulders, thoracic and
lumbar kyphosis, posterior pelvic tilt
 Cspine impairments- c/s joint stiffness, lengthened lower cervical erectors,
anterior throat muscles, shortened levator scap, scalene, upper trap
o Tx- mob, stretch UT, scalene, levator scapulae
o Forward head posture= chin tucks
 Tspine impairments- T/s stiffness, lengthened Upper thoracic erectors and
scapular retractors, shortened pecs, decreased shoulder ROM
o Tx- pec stretch, shoulder rolls, scapular pinches
 Lspine impairments- posterior pelvic tilt, weakened abdominals and lumbar
erectors weakened hip flexors, tight hamstrings
o Tx- abdominal strengthening, iliopsoas strengthening, LB
strengthening, hamstring stretch
 Maintaining posture- lumbar roll, ergonomics, stretch at work
 Contraindications
o Significant balance deficits, intense fear of ball, pain with sitting, pain
with exercises, boney spinal instability, acute pain, ringing in ears
 Indications- decrease in ROM, strength, balance, coordination, endurance,
proprioception
 Pilates
o Rigged spring beds so bedridden can do light resistance exercise,
integrates trunk pelvis, shoulder girdle, engages deep abdominal and
spine muscles to develop a strong core, increased length, strength
and flexibility, teaches neutral alignment of the spine, strengthens
deep postural muscles for support, mental focus for efficiency and
mm control
 Neutral spine- draw abs in imprint low back on ground, sacral base shouldn’t
leave the ground with exercise
Aquatic PT
 Buoyancy- T11 in humans. Force of gravity replaced by increased F of h2o
 Power of buoyancy- supports, resists, assists
 Depth & WBo ASIS- 56%
o Xiphoid 30%
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o C7 10%
o Over head 0%
o Deeper= less weight bearing
%WB with fast walking in h20
o depth of immersion=%WB
o C7-25%
o Xiphosternum 50%
o ASIS 75%
o Still GRFs
Clinical application- 200lb athlete with a stress fx, 50% weight bearing
restriction. How deep must the client go in order to stay within these
restirctions
o 50/200- .25 x 100=25%, C7 for fast walking
Relative Density= 1
o Float- RD <1, higher body fat %, inhale, flaccid
o Sink- RD >1, lean muscle mass, exhale, spasticity
Buoyancy works- water provides an environment to perform a progressive
program from passive to resistive. The type of exercise is dependent upon
movement, limb position, and equipment use
Therapeutic benefits of buoyancy- decreased WB/decreased joint
compression forces= decreased pain, decreased effects of gravity, provides
safe environment to perform passive, active assistive, and resistive exercise
VMO activation- VMO activation was 50% waist deep and 25% chest deep
compared to land. Follows what we know about buoyancy support.
Shallow vs deep water running- study found significinatly greater loss of
stature in participants who performed treadmill and shallow water running
compared to deep water running. Disc herniations etc
Problems with buoyancy- therapist may have difficulty remaining in a fixed
position, may be difficult tos tbailize the patient, patient may experience less
proprioceptive input, flaccid extremities may float
Rotational forces- rotate around COM until up/down forces match
Drag forces related to surface area
FD= PCV2A/2G
o FD= force drag, P= fluid density, C= coefficient of drag (how
streamlined is an object?), V= velocity (m/sec), A=frontal area of
object, G=gravitational constant
Hydrotone bell orientation and velocity of movement have considerable
effect on foce production. 50% more force produced with bell at 45º angle
compared to 0º when velocity was 152 cm/sec
With slow velocity 31 cm/sec was close to equal in both positions
Eddies- can be used to assist a patient- breaks H20, PT walks in front
Benefits of viscosity- strengthens muscles in both directions, resistance can
be controlled by speed and surface area= progressive in nature, slows
movement allowing for improved quality, smoothing out jerky motions and
provides increased time response for pts equilibrium rxns
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Benefits of turbulence and flow- increased resistance= increased strength
and endurance, training speed moves up to ~ 90º/sec, utilizing eddies to
assist movement through the water for ROM and relaxation, resulting drawg
will have dampening effect on involuntary movement, turbulence increases
proprioceptive feedback and can be used to treat tactile defensiveness and
challenge pts during balance and stabilization exercise
Effect of aquatic backwards locomotion- good for improving extension
strength in pts after lumbar discectomy
Controlling cadence= controlling resistance- noted increased ES mm
activation during horizontal shoulder abduction/adduction especially with
addition of increased water turbulence
GRF: running= 2-4x body weight, jumping 5x, but pool= softer landings and
stronger take off still some GRFs
Hydrostatic pressure- deeper= increased pressure
Benefits of hydrostatic pressure- aids in resolution of edema (increased with
depth), helps build inspiration mms, reduces heart rate in water
20-30 mL of swelling= VMO inhibition, 50-60mL rectus VL
HTN decrease the edema reducing effect of hydrostatic pressure? Pressure
caused by the water must be greater than the diastolic pressure to creat a
pressure gradient. Normal BP 120/80, at 4ft depth 88.88mmHg of pressure12 inches x 4 ft/.54. Harder for flow if BP is higher
Water temperature
o Warm water 88-90+ good for neurological, chronic pain, fibromyalgia,
pediatric
o Cooler water- 82-86- orthopedic dx, athletes, MS, pregnancy
USE RPE, BERG, increased BV= have to pee, increased 60% breathing
Contraindications- like for exercise- DVT, fever, bowel and bladder,
hydrophobic, wounds, heart issues, intoxication, dialysis, high BP
Equipment- floatation, buoyancy, resistance by drag or increased surface
area, mask and snorkel, shoes, steps, weights, tubing, theraband, sticks
Progression
o Buoyancy, drag forces (increased speed, surface area, turbulence),
stable to dynamic position, isolated vs complex movement patterns,
increased lever arm, equipment use
Shallow ater- functional training, progressive WB, for the hydrophobic pt,
starting point for non-swimmer or those unable to stabilize in deep water,
post-op spinal fusion, SI jt dx
Normal Gait- key points that need to occur at each phase of gait to ensure
normal gait patterns
o IC: heel first contact, LR= controlled knee/ankle with hip stability,
MS= controlled ankle rocker with knee extended, TS= locked
ankle/heel rise of trailing limb, P+Iswing=knee and hip flexion, MSTS- further hip flexion, ankle DR, vertical tibial to extend knee
Differences in pool
o Balance rxs need to be faster and stronger on land
o Proprioceptive feedback from viscosity, Hydrostatic pressure, and
turbulence can provide sensory feedback to a limb that is not on land
o Decreased WB/jt compression from force of buoyancy may reduce
proprioceptive input, mm force is different due to drag forces and
buoyancy
 Mms activity with water walking
o Hip extensors concentric LRMS vs eccentrically flexion torque
o Hip flexion assisted during swing
o Hamstring eccentric @ TS and LR not as great due to buoy.
o Quad greater resistance MS TS due to drag
o DR assisted by buoyancy swing and LR
 Muscle activation intensity (%MVC)
o VM, Rectus, BF, and gastroc activity higher than land
o Backward walking higher mm activity of paraspinals, VM, TA
o If walk at desired speed- less mm activation, force them to walk faster
for mm activation, can work otherside, turn them around
Osteoporosis
 1 in 3 women, 1 in 5 men
 Low bone mass, and bone matrix deteriorationincreased fragility & risk fx
 Silent disease, take 1000-1200mg from diet Ca is best, vitamin D
recommended, 90% bone mass by 18 y/o
 25% of people die 6-12 mo. Post hip fx
 Bone physiology
o Cortical bone- stronger outer layer is resisted bending
o Trabecular bone-spongy interior scaffolding resists compression
o Healthy bone= balance of osteoblasts/clasts
o Trabecular- where the most loss occurs. Higher fx risk
 Density and mass declines with age (bone)- resorption outpaces formation,
also expansion of marrow space by fat
 Most common fx sites- vertebral (have more trabecular bone), hip, wrist
o Spine- front (bodies) have soft spongy, elss dense TRABECULAR bone,
the back (pedicles, SP) are more solid dense CORTICAL bone
o Wedge fx, biconcave fx, crush fx (whole vert break down). Slide 24
 Tennis players-35% more bone in playing arm
 Density- DEXA/QCT, Architecture XTREME CT, fx risk- FRAX
o DEXA- low dose xray, density in T-score, referenced against age, sex,
ethnicity for risk of fx- FRAX (fx risk assessment tool)
o 3D quantitative CT (QCT)- measure BMD of spongy interior vs dense
cortical. Earlier changes seen, higher radiation
 Medications
o Bisphosphonates- Fosamax, Actonel, Boniva. Decrease bone loss,
cause GI side effects. Prevent loss, don’t build new bone
o Estrogen receptor modulators-evista, decreases bone loss
o PTH- Forteo- helps form bone using a high risk pt (only 2 yrs can
increase bone density)
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o Also ERT/HRT- side effects increased risk stroke, blood clots, breast
and ovarian cancer
External spine properties- muscle strength, force, spine load, posture
Spine flexion is the weakest and most fragile position
Thoracic kyphosis increases spinal loads- peak flexion moment T8, apex of
curve T8 cervical shift
Decline type II fibers with age
MM force increases with kyphosis- 40% increase in spinal extensor force at
T7/8, flexion=less strength and more imbalance
Local spine properties- geometry, shape, size, thickness
o IVD degen predispose anterior vertebral Fx in thoracolumbar
spine= stress shielding
Neurophysiologic properties- motor control, function, pain, balance, NM
Extension exercises maintain shape of vertebrae and avoids compression on
the spine- prevent natural progression of kyphosis
Older- longer warm up, stretch 60 sec, adjust hr (220-age), provide
appropriate stimulus to strength training- intensity, repetitions, sets,
duration, frequency and specificity
80% 1RM optimal, need atleast 60% or 15 RM for functional gain, 2-3x/wk
for each mm group, specificity!
Comorbities
o Frailty- start 50% 1rm- for motor learning and efficiency
o Osteoarthritis- not normal wear and tear, weakness is primary risk
factor for OA. Need adequate warm up and stretching (don’t over do
it), begin few reps at low resistance
o COPD (exercise needed), CAD (moderate training), osteoporosis
Tx priorities- protect from fx first, learn optimal spine posture, learn to hip
hinge, avoid all flexion, deep rotation, and sidebending, learn to breathe with
good rib movement and engage the deep abdominal stabilizers, learn static
and dynamic balance strategies