Stanbridge - T4 - TE2 - W2 - Spine & Posture Part 2

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Questions and Answers

Which of the following techniques is NOT recommended for managing discomfort from a particular posture?

Maintaining flexibility while promoting circulation

Performing motions slowly and throughout the day

Performing AROM in the opposite direction of postural dysfunction

Making rapid movements through full available ROM (correct)

Which spinal motion is recommended to support the lumbar spine?

Flexion only

Extension and flexion (correct)

Rotation only

Standing without movement

What is one of the key components of spinal stability?

Involvement of three subsystems: passive, active, and neural (correct)

Avoidance of any movements to prevent strain

Exclusive reliance on passive structures like bones

Active engagement of breathing techniques

Which muscle relaxation technique involves shoulder movements?

Shoulder circumduction Signup and view all the answers

What should individuals with a sitting job do to manage spinal discomfort?

Stand and walk at regular intervals Signup and view all the answers

What is a primary reason for spinal instability according to the highlighted factors?

Poor neuromuscular control Signup and view all the answers

Which muscle type is primarily responsible for providing dynamic support to the spinal segments?

Segmental muscles Signup and view all the answers

How do superficial (global) muscles primarily stabilize the spine?

By providing compressive loading Signup and view all the answers

What muscle fiber type is more prevalent in postural muscles, contributing to higher muscle endurance?

Type I fibers Signup and view all the answers

What can inactivity lead to regarding muscle composition and function in the context of spinal stability?

Decreased muscle endurance and increased fatty infiltrates Signup and view all the answers

What muscle groups are typically weak and elongated in a relaxed and slouched posture?

Lower rectus abdominis and external obliques Signup and view all the answers

What is a common source of symptoms related to flat low back posture?

Posterior longitudinal ligament strain Signup and view all the answers

Which of the following is NOT a common cause of lordotic posture?

Increased hip extension Signup and view all the answers

Which posture is characterized by a protracted scapula and forward head position?

Kyphotic posture Signup and view all the answers

What impairments are associated with relaxed and slouched posture while sitting?

Thoracic kyphosis and lumbar flexion Signup and view all the answers

What is a notable change in the deep multifidus muscle observed in patients with low back pain?

Impaired timing of anticipatory activity Signup and view all the answers

Which of the following changes is associated with cervical spine pain according to the studies?

Atrophy of cervical extensor muscles Signup and view all the answers

What behavioral change is noted in participants with recurrent low back pain when faced with increased mechanical demands?

Decreased duration of activation in deep fibers Signup and view all the answers

Which of the following best describes the changes in neural control observed in patients with cervical spine pain?

Increased reliance on superficial muscles for stability Signup and view all the answers

What impact does altered muscle recruitment have on everyday activities for patients with cervical spine pain?

Decreased ability to generate interpersonal torque Signup and view all the answers

Study Notes

Therapeutic Exercise II - PTA 1010 - Spine Part 2 (Posture)

Course focusing on posture and spinal stability
Objectives include describing normal and abnormal postures, understanding common pain syndromes, and evaluating the role of inert, dynamic, and neurological structures on spinal stability.
Recognizing the difference between global and segmental muscle activity affecting spinal stabilization at all levels is also a focus.
Instruction of proper posture in static and dynamic activities, proper implementation of exercise, and development of healthy habits using ergonomics, body mechanics, stress management, and relaxation to avoid injury.

Outline

Posture and related pain syndromes
Generalized guidelines for managing spinal impairments
Spinal Stability

Posture and Pain Syndromes

Recent article highlights posture's role in spinal dysfunction as a hot topic in the physical therapy community.
Some believe posture is a main cause of pain and dysfunction while others feel it's a normal part of life.

Posture (Physiotherapists' Perceptions)

Study investigated physiotherapists' views on optimal standing and sitting posture.
Clinicians often use "corrective" posture interventions.
Results show 93.9% of physiotherapists viewed the education of optimal posture as important, with three sitting postures most commonly selected as optimal.
There were also 2 most commonly selected standing postures.

Posture (Physiotherapists' Perceptions) - Methods

Online survey comprised three sections focused on:
Importance of postural education in clinical practice
Choice of optimal postures (sitting and standing)
Physiotherapist demographic information

Posture (Physiotherapists' Perceptions) - Results

93.9% of participants valued postural education.
Three sitting postures were commonly selected as "optimal".
Two standing postures were cited as optimal by 98.2% of the participants.
Participants used similar rationales when identifying "optimal" postures. Six major themes were linked to their decision: natural spinal curves, muscle recruitment and energy expenditure, optimal pelvis position, neutral spine, stereotypes for an "ideal" posture and line of gravity (only used for standing).

Posture (Physiotherapists' Perceptions) - Clinical Implications

Evidence demonstrates that healthy individuals commonly maintain relaxed and flexed sitting postures.
Strong opinions on posture may influence clinical advice; however, evidence-based practice should be prioritized, and strong postural beliefs should be considered alongside any clinical advice given to patients.
Clinical implications suggest potential for harm from prescribing postures without evidence, and the importance of considering all factors when advising patients.

Posture(Physiotherapists' Perceptions) -Clinical implications

These beliefs are likely to influence advice given to patients on postural re-education and may lead to advice and education that, at best, has not been supported by evidence, and at worst, is harmful by creating a "problem" when there was none to begin with.

Three categories to describe pain from postures.
1. Postural Fault: deviations from normal alignment with no structural impairments (e.g., slouching in a chair).
2. Postural Pain Syndrome: pain from maintaining a faulty posture for prolonged periods.
3. Postural Dysfunction: pain due to prolonged poor posture or resulting from adhesions formed after trauma or surgery.

Common Faulty Postures: Characteristics and Impairments

Issues like lordosis, slouching, and flat back posture in the pelvic and lumbar regions.
Forward head and kyphotic/flat upper back and neck postures.
Frontal plane deviations (scoliosis and lower extremity asymmetries).

Lordotic Posture:

Increased lordosis, anterior pelvic tilt, and hip flexion.
Often seen with increased thoracic kyphosis and forward head. -Mobility and muscle impairments include tight hip flexors (Iliopsoas, TFL, and rectus femoris), tight lumbar extensors (erector spinae), and weak or stretched abdominal muscles (including rectus abdominis, internal/external obliques, and transverse abdominis).
Passive structures like the ALL, narrowing of the intervertebral foramen, compression of nerve roots, and approximation of facets can experience stress.
Common causes include sustained faulty posture, pregnancy, obesity, and weak abdominals.

Relaxed and Slouched Posture (Swayback):

Shift of the entire pelvis segment anteriorly and hip extension, a posterior shift of the thoracic segment and thoracic flexion, and a flattening of the low lumbar area.
Mobility impairments in the upper portion of the rectus abdominus, upper fibers of the internal oblique, intercostals, and hip extensors (if lordotic) are possible.
Possible impairments in muscle performance include weak or elongated lower rectus abdominus, external oblique muscles, extensor muscles of the lower T/S, hip flexors, and neck flexors.
The ilio-femoral ligaments, anterior longitudinal ligament (lower lumbar spine, if lordotic), posterior longitudinal ligament, upper lumbar, thoracic spine, narrowing of the intervertebral foramen, and facet approximation can experience stress and pain.
Likely causes include fatigue, faulty posture, weakness, and poor exercise program design.

Flat Low Back Posture:

Decreased lumbar lordosis, posterior tilt of the pelvis, and an often-observed forward head posture.
Potential impairments encompass weak or stretched trunk flexors (rectus abdominus, intercostals), hip extensors, and lumbar extensors.
Possible causes include slouching or an overemphasis on flexion exercises.

Round Back: Increased Kyphosis with Forward Head:

Increased thoracic kyphosis, protracted scapula, forward head, increased flexion of the lower C/S and upper T/S, also potentially increased extension of the occiput on C1.
Muscle tightness in intercostals, pectoralis major and minor, latissimus dorsi, serratus anterior, levator scapulae, SCM, scalenes, upper trap and the muscles of the suboccipitals are plausible.
Possible muscle performance impairments in the lower C/S/upper T/S erector spinae, scapular retractors/rhomboids, middle trapezius, anterior throat/suprahyoid & infrahyoid muscles, capital flexors (rectus capitus anterior and lateralis, and longus colli and longus capitis) are concerns.
Inert tissue concerns include ALL; PLL, ligamentum flavum in the lower C/S and T/S, possibly facet joint irritation in the upper C/S.
Potential upper C/S narrowing in the intervertebral foramen, TOS from impingement of the neurovascular bundle from the anterior scalene and pectoralis minor tightness.
Potential causes involve slouching, poor ergonomic setups, or overemphasis of flexion exercises in training programs.

Flat Upper Back and Neck Posture:

Decreased T/S curve, depressed scapula, depressed clavicles, Decreased C/S lordosis with increased flexion of the occiput on the atlas.
Impairments are believed to include tight anterior neck, T/S erector spinae, and scapular retractors.
Possible muscle performance impairments involve scapular protractors, and the anterior thorax intercostal muscles.
Potential symptoms and causes include postural muscle fatigue, compression of the neurovascular bundle between the clavicle and ribs, TMJ pain from changes in occlusion, loss of normal spine curve, which causes decreased shock absorption.

Scoliosis:

Lateral curvature of the spine. -Structural: irreversible lateral curvature with fixed rotation. -Non-structural or postural: reversible lateral curvature with no fixed rotation, changing with posture changes.
- Thoracic Spine: rib prominence posteriorly on the side of convexity and anteriorly on the side of concavity.
Possible anatomical causes include neuromuscular diseases, osteopathic disorders, and idiopathic causes.
Possible nonanatomical causes include leg length discrepancy, and or muscle guarding/postural habits.

Spinal Stability

Provided by three subsystems: passive (bones and ligaments), active (muscles), and neural control systems.
Instability is commonly connected to inert tissue damage (ligaments, discs), insufficient muscular strength/endurance, and poor neuromuscular control.

Spinal Stability: Active Subsystem

Multiple muscles work together to create spinal stiffness and stability.
No single muscle is the primary stabilizer.

Spinal Stability: Muscles

Superficial/global muscles stabilize through compression; limited effectiveness.
Deep/segmental muscles have direct attachments to provide dynamic support to individual spinal segments and maintain stability.

Spinal Stability: Neurological Control

The nervous system coordinates muscle responses to expected and unexpected forces. This involves modulating stiffness and movement to match the forces acting on the spine.

Spinal Stability: Effects of Limb Function

Without proper spine stability, limb-girdle muscle contractions transmit forces up the spine, which causes excess pressure on the spinal structures and supporting tissues.
Injury can occur with lower, repetitive, or traumatic forces below 20 lbs.

Psychosocial Risk

Fear avoidance can affect neuromuscular control and lead to deconditioning syndrome.
Use of Fear Avoidance Belief Questionnaire (FABQ) aids in identifying the need for cognitive behavioral therapy with regards to pain.

Effects of Breathing on Posture and Stability

Normal ventilation does not significantly affect spinal stability.
Breathing under stress, particularly inhalation, often leads to back extensor activation, increased spinal stability, and function of the intercostal muscles. . Exhalation generally decreases spinal stability, associated with back flexion.

Effects of Intra-abdominal Pressure and the Valsalva Maneuver

The Valsalva maneuver involves forcibly exhaling against a closed glottis.
It causes co-contraction of the transversus abdominis, internal oblique, and external oblique muscles, potentially unloading spinal compressive forces and providing a stabilizing effect by pushing the abdominal muscles out.
It prevents buckling of the spine.

Spinal Stability: Passive Subsystem—Inert Tissues

C/S and T/S facet orientation, L/S facet orientation, ribs, spinous processes, intervertebral discs, ligaments, and thoracolumbar fascia are considered inert tissues. Thoracic and lumbar fascia are static and dynamic.

Segmental Instability

Instability can result from impairments/injury. It can also stem from the hypomobility of another segment, degeneration, or congenital defects.
Pain is often reproduced with aberrant segmental movement, maintained positions, or stresses the muscles cannot control. Segmental instability occurs when a segment does not function in its neutral spine/zone. An unstable segment can lead to pain by placing stresses on the passive osteoligamentous structures. This occurs outside of the neutral zone (R1-R2).

Spinal Stability Assessment

A simple muscle strength test (MMT) may not give a full picture of spine musculature function.
Core muscle activation assessment (cervical or lumbar spine) determines if the correct muscles are utilized, which can be evaluated by endurance tests,

Cervical Stability Examples - Endurance Assessment

Tests including cranial cervical flexion, neck flexor endurance, and deep neck extensor endurance would be included in a TMT course.

Lumbar Spine Stability Assessment Examples

Evaluations include endurance in side support, performing SL bridges, prone hip rotation, supine hip abduction, and prone knee flexion.
Testing should include a functional assessment and palpation for multifidus lift at specific locations.

Stabilization Exercises

Stabilization exercises should avoid excessive flexion or extension, starting from the initial position.
The exercises often referred to as anti-rotational exercises.
Movements that create spinal rotation are usually employed isometrically to prevent rotation while limbs are loaded.

Stabilization Exercises - Performing in Neutral Spine vs. Functional Spine

Perform in neutral spine to minimize pain, then move into functional spine if needed to provide the greatest comfort without pain.

C/S Stabilization Exercises: Training of the Deep Flexors 10x10"

Exercises involve utilizing a device designed for biofeedback.

Supine C/S Stabilization Exercises - Deep C/S Flexors

Involves the performance of repetitive movements and specific directional guidance to align the spine correctly in an appropriate neutral zone.

Prone C/S & Scapular Stabilization Exercises

Exercises are performed while the patient is lying prone while using proper resistance to promote stabilization in the spine.

Progression on Unstable Surfaces

Patient progression is facilitated by gradually increasing resistance and moving to more functional positions on unstable surfaces.
Specific progression exercises are available, and the appropriate progression is based on the ability of the patient to perform the skill in their particular starting posture without pain.

Trunk Muscle Highest Level of Activity

Specific exercises/movements that will show the spinal stability in their greatest intensity are recommended and listed to promote and maximize the activity of the primary stabilizing muscles of the spine.

Basic Abdominal Stabilization Progression: Supine

The exercises in this category, using TrA and multifidus activation with global flexors, are performed in a supine position, with progressively increasing difficulty, to prepare for movement on unstable surfaces.

Stabilization Exercises in Quadruped

Using a tactile rod in the quadruped posture will help ensure a neutral zone position is identified and the appropriate supportive muscles are used.

Basic Stabilization Progression for Core and the Global Lumbar Extensors

The patient will be progressed on exercises by adding in movement to the limbs to increase the difficulty so there is continued progression. If there is hip flexor tightness a pillow/support will assist in increasing the difficulty.

Generalized Guidelines for Managing Spinal Impairments

Acute Phase: Patient education on pain relief positions, kinesthetic awareness training, muscle performance training, and basic functional movement training.
Subacute/Controlled Motion Phase: Patient education on pain modulation, kinesthetic training, stretching/manipulation, muscle performance, cardiopulmonary conditioning, postural management, and proper body mechanics in functional activities.
Chronic/Return to Function Phase: Work hardening, graduated return-to-play/sport programs, conditioning, and high-intensity/repetitive programs.
Return to Function Phase: Repetitive lifting, repetitive reaching, repetitive pushing/pulling, rotation/turning activities, transitional movements, and transfer training.

Cardiopulmonary Endurance

Program goal is to increase cardiovascular endurance to improve overall health and symptom relief.
Exercise modality selection is based on identified spinal bias (flexion, extension, neutral).
Includes a warm up, exercise program, and cool down.

Common Aerobic Exercises and Effects on the Spine

Aerobic exercise type selection for spine is based on individual diagnostics with directional preferences.
Types listed include cycling, walking, running, stair climbing, cross-country skiing, ski machines, and cardio machines, step aerobics, and other trending exercises.

Did We Meet These Objectives?

Identified objectives include understanding tempo-mandibular joint dysfunction, describing normal and abnormal postures, recognizing painful spinal syndromes, understanding the interacting roles of inert, dynamic, and neurological structures, and differentiating global and segmental muscle activity on spinal stabilization.

References

A large list of references are provided to aid in the study of the material.

Studying That Suits You

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Description

Test your knowledge on spinal stability and posture management techniques. This quiz covers various aspects of spinal health, including muscle types, spinal motions, and recommended practices for maintaining comfort in sitting jobs. Perfect for anyone interested in ergonomics and physical wellness.