Advanced Physical Therapy Techniques for Spinal Disorders PDF

Advanced Physical Therapy Techniques for Spinal Disorders Dr. Maha Alibeiny Associate Professor of Orthopedic physical therapy, Cairo University [email protected] Mechanical Diagnosis and Therapy (MDT) Ob...

Advanced Physical Therapy Techniques for Spinal Disorders Dr. Maha Alibeiny Associate Professor of Orthopedic physical therapy, Cairo University [email protected] Mechanical Diagnosis and Therapy (MDT) Objectives By the end of this part the students will be able to; Describe the MDT approach. Understand the MDT technique basic syndromes. Differentiate between centralization and prephralization symptoms. Identify clinical picture of MDT technique syndromes. Recognize the exercises used in the MDT approach for the lumbar spine disorders.  MDT uses primarily self-treatment strategies, and minimizes manual therapy procedures, with the McKenzie- trained therapist supporting the patient with passive procedures only if an individual self-treatment program is not fully effective.  The McKenzie method (also MDT) is a comprehensive method of care primarily used in physical therapy. New Zealand physical therapist Robin McKenzie, (1931–2013) developed the method in the late 1950s. In 1981 he launched the concept which he called Mechanical Diagnosis and Therapy (MDT) – a system encompassing assessment (evaluation), diagnosis and treatment for the spine and extremities. MDT categorizes patients' complaints not on an anatomical basis, but subgroups them by the clinical presentation of patients. Lateral Shift Correction Self correction Mckenzi ext. (1-4), flex (5,6) Techniques to Increase Lumbar Extension Techniques to Increase Lateral Flexibility in the Spine Core Stability  Core Stability ILOS : By the end of this part the students will be able to; Define core stability (CS) Understand three major systems of CS Differentiate between global and local stabilization systems. Review attachments of thoracolumbar fascia and its implication on the CS. Describe muscle control of the cervical spine. Recognize the neurological control on the CS. Describe effects of limb function on CS. Describe effects of “Valsalva maneuver” on CS. Core stability ▪ The word “core” and the idea of training the “core” has become very popular ▪ In spite of its popularity, a universally accepted definition of “core stability”, “core” and the muscles that constitute the “core” has yet to be established Core Stability Core Stability Definition: Ability to control the position and motion of the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segment in integrated kinetic chain activities. Three Major Systems of Core Stability Bergmark’s Muscle Classification System (1989)  Thoracolumbar Fascia The thoracolumbar fascia is an extensive fascial system in the back that consists of several layers. It surrounds the erector spinae, multifidi, and quadratus lumborum, thus providing support to these muscles when they contract. Increased bulk in these muscles increases tension in the fascia, perhaps contributing the stabilizing function of these muscles. The aponeurosis of the latissimus dorsi and fibers from the serratus posterior inferior, internal oblique, and transverse abdominis muscles blend together at the lateral raphe of the thoracolumbar fascia, so contraction in these muscles increases tension through the angled fascia, providing stabilizing forces for the lumbar spine. In addition, the “X” design of the latissimus dorsi and contralateral gluteus maximus has the potential to provide stability to the lumbosacral junction. The “X” design (the serape effect) created by the superficial layer of the thoracolumbar fascia with the latissimus dorsi and contralateral gluteus maximus.  Muscle Control in the Cervical Spine The fulcrum of the head on the spine is through the occipital/ atlas joints. The center of gravity of the head is anterior to the joint axis and therefore has a flexion moment. The weight of the head is counterbalanced by the cervical extensor muscles (upper trapezius and cervical erector spinae “SC”). Tension and fatigue in these muscles, as well as in the levator scapulae (which supports the posture of the scapulae), is experienced by most people who experience postural stress to the head and neck. Multifidus, With its segmental attachments, the multifidus is thought to have a local stabilizing function in the cervical spine similar to its function in the lumbar region The position of the mandible and the tension in the muscles of mastication are influenced by the postural relationship between the cervical spine and head.  Mandibular Elevator Group The mandible is a movable structure that is maintained in its resting position with the jaw partially closed through action of the mandibular elevators (masseter, temporalis, and medial pterygoid muscles). Suprahyoid and infrahyoid group: The anterior throat muscles assist with swallowing and balancing the jaw against the muscles of mastication. These muscles also function to flex the neck when rising from the supine position. With a forward head posture, they, along with the longus colli, tend to be stretched and weak so the person lifts the head with the sternocleidomastoid (SCM) muscles. In addition, with a forward head posture, the suprahyoid muscles have a tendency to pull the mandible into depression due to their orientation and attachments at the hyoid and mandible. This is counteracted by the mandibular elevator muscle group, which creates a sustained contraction in order to keep the mouth closed.  Rectus Capitis Anterior and Lateralis, Longus Colli, And Longus Capitis The deep craniocervical flexor muscles have segmental attachments and provide dynamic support to the cervical spine and head. The longus colli is important in the action of axial extension (retraction) and works with the SCM for cervical flexion. Without the segmental influence of the longus colli, the SCM would cause increased cervical lordosis when attempting flexion.  Role of Muscle Endurance Strength is critical for controlling large loads or responding to large and unpredictable loads (such as during laborious activities, sports, or falls), but only about 10% of maximum contraction is needed to provide stability in usual situations. Slightly more might be needed in a segment damaged by disc disease or ligamentous laxity when muscles are called on to compensate for the deficit in the passive support. It was reported that poor muscular endurance in the back extensors muscles is greatly associated low back pain. Greater percentages of type I fibers than type II fibers are found in all back muscles, which is reflective of their postural and stabilization functions. Three Major Systems of Core Stability  Neurological Control: Influence on Stability The muscles of the neck and trunk are activated and controlled by the nervous system, which is influenced by peripheral and central mechanisms in response to fluctuating forces and activities. Basically, the nervous system coordinates the response of muscles to expected and unexpected forces at the right time and by the right amount by modulating stiffness and movement to match the various imposed forces.  Feed-forward Control and Spinal Stability The CNS activates the trunk muscles in anticipation of the load imposed by limb movement to maintain stability in the spine. It was reported that there are feed forward mechanisms that activate postural responses of all trunk muscles preceding activity in muscles that move the extremities and that anticipatory activation of the transversus abdominis and deep fibers of the multifidus is independent of the direction or speed of the postural disturbance. Feed-forward Control and Spinal Stability (cont.) The more superficial trunk muscles vary in response depending on the direction of arm and leg movement, reflective of their postural guy wire function, which controls displacement of the center of mass when the body changes configuration. Differences in patterns of muscle recruitment in patients with LBP with delayed recruitment of the transversus abdominis in all movement directions and delayed recruitment of the rectus abdominis, erector spinae, and oblique abdominal muscles specific to the direction of movement compared to healthy subjects were reported. Effects of Limb Function on Spinal Stability Without adequate stabilization of the spine, contraction of the limb- girdle musculature transmits forces proximally and causes motions of the spine that place excessive stresses on spinal structures and the supporting soft tissue. Clinical Tips: Stabilization of the pelvis and lumbar spine by the abdominal muscles against the pull of the iliopsoas muscle is necessary during active hip flexion to avoid increased lumbar lordosis and anterior shearing of the vertebrae. Stabilization of the ribs by the intercostal and abdominal muscles is necessary for an effective pushing force from the pectoralis major and serratus anterior muscles. Stabilization of the cervical spine by the longus colli muscle is necessary to prevent excessive lordosis from contraction of the upper trapezius as it functions with the shoulder girdle muscles in lifting and pulling activities. Localized Muscle Fatigue Localized fatigue in the stabilizing spinal musculature may occur with repetitive activity or heavy exertion or when the musculature is not utilized effectively due to faulty postures. There is a greater chance of injury in the supporting structures of the spine when the stabilizing muscles fatigue. N.B Significant changes in motion patterns between the spine and lower extremity joints as well as significant changes in muscle recruitment patterns with repetitive lifting during an extended period of time, resulting in increased anterior/posterior shear in the lumbar spine were reported. Muscle Imbalances: Imbalances in the flexibility and strength of the hip, shoulder, and neck musculature cause asymmetrical forces on the spine and affect posture causing “faulty postures.”  Effects of Intra-abdominal Pressure (IAP) and the Valsalva Maneuver on Stability During the valsalva maneuver, contraction of the TrA, IO, and EO muscles increase IAP. Contraction of the TrA alone pushes the abdominal contents up against the diaphragm; therefore, to complete the enclosed chamber, the diaphragm and pelvic floor muscles contract in synchrony with the TrA. There are several ideas that explain how IAP improves spinal stability. The increased pressure in the enclosed chamber may act to unload the compressive forces on the spine as well as increase the stabilizing effect by pushing out against the abdominal muscles, increasing their length-tension relationship and tension on the thoracolumbar fascia. It is also suggested that the IAP may act to prevent buckling of the spine and thus prevent tissue strain or failure. A Increased intra-abdominal pressure (IAP) pushes outward against the transversus abdominis and internal obliques, creating increased tension on the thoracolumbar fascia, resulting in improved spinal stability. B Reduced pressure decreases the stabilizing effect.  The Valsalva Maneuver : 1. is a technique frequently used by individuals lifting heavy loads and potentially has cardiovascular risks , so it is recommended that individuals be taught to exhale while maintaining the abdominal contractions to decrease the risks. 2. In addition, it was found that if a static expulsive effort is maintained (holding the breath while contracting the abdominal muscles), activation of the transverse abdominis is delayed. Because activation of the transversus abdominis is necessary for segmental spinal stability, expiration during exertion reinforces this stabilizing function. Impaired Posture: In order to make sound clinical decisions when managing patients with activity or participation restrictions due to spinal impairments, it is necessary to understand the underlying effects of faulty posture on flexibility, strength, and the pain experienced by the individual. Impaired posture may be the underlying cause of the patient’s pain or may be the result of some traumatic or pathological event. Exercises to improve muscle performance, cardiopulmonary endurance, and functional activities are integrated over a background of activating the deep segmental and global multi-segmental spinal stabilizing musculature. Core Muscles Training (Practical) Deep Segmental Muscle Activation and Training for cervical Musculature Deep Segmental Muscle Activation and Training for lumbar Musculature Global Muscle Stabilization Exercises for the cervical region Global Muscle Stabilization Exercises for the lumbar region Spinal stabilization and cardiopulmonary endurance exercises Spinal stabilization and functional training Transitional Stabilization Exercises Spinal Traction  Spinal Traction ILOS: By the end of this lecture the students should be able to : Define spinal traction technique. Describe the therapeutic effects, indications, contraindications and precautions of the spinal traction techniques. Recognize the different types of the spinal traction techniques. Infer the clinical tips for the spinal traction techniques.  Definition Spinal traction is defined as the use of traction forces applied to the cervical and lumbar spine via various mechanical systems. It is described as the application of traction techniques by using tables, pulleys, cables, and weights for the treatment of cervical and back pain disorders.  Cervical Spine Enhancement of fluid exchange and nutrient transport within the disc. Increase that intervertebral foramina dimensions during traction application. Therapeutic Reduction of disc herniation Effects and extension (when measured Indications immediately after traction). Affects the activity of cervical spine musculature. N.B. The duration of any observed biomechanical or physiological effect is not known. Lumbar Spine Enhancement of fluid exchange and nutrient transport within the disc. During passive traction, intradiscal pressures can be reduced or become negative. Traction from patient generated forces may increase intradiscal pressures. These pressures are thought to rapidly return to their prior state when traction ceases. The expanse of herniated disc material is suggested to reduce in some subjects during traction. Most single observation studies suggest the effect is temporary. A cumulative effect with repeated traction sessions may occur, but evidence of such is very limited.  Traction techniques: Motorized Pneumatic Traction Weighted Traction Autotractive Traction Positional Traction Inverted Traction Manual Traction  Contraindication 1. Spinal disease, infection, inflammation, and tumor—induces further damage 2. Vertebral fracture or dislocation—damages the spinal cord due to increased joint mobility 3. Spinal instability or hypermobility—damages the spinal cord due to increased joint mobility 4. Severe disk herniation—enhances herniation 5. Vertebral arterial dysfunction—creates vascular damage 6. Spinal cord stenosis—enhances compression of the spinal cord 7. Osteoporosis—vertebral fracture 8. Arthritis and rheumatoid arthritis—enhances degeneration 9. Aortic aneurysm—hemorrhage 10. Abdominal hernia—enhances the condition 11. Uncontrolled hypertension—enhances the condition 12. Pregnancy (lumbar traction only)—complications  Precautions 1. Pain exacerbation—traction force may cause sudden and unexpected exacerbation of cervical or lumbar pain. If present, stop treatment and reassess the need for traction therapy. 2. In patients with history of spinal surgery—may lead to complications 3. In patients suffering from spondylolysis and spondylolisthesis— traction may lead to spinal hypermobility. Careful monitoring of the condition throughout treatment is necessary. 4. In patients with respiratory and hypertensive disorders—may enhance the conditions. These patients should be observed for signs of distress during initial application. 5. In patients with dentures—may cause undue pressure on the dentures if an occipitomandibular halter is used. Use only an occipital halter. 6. In patients with temporomandibular (TMJ) dysfunction—may aggravate the condition if an occipitomandibular halter is used. Use only an occipital halter.  Clinical prediction rules have recently been developed and tested. The results suggest that patients older than 55 years who show positive cervical distraction tests, nerve tension tests, shoulder abduction tests, and peripheralization of symptoms are most likely to benefit from cervical traction therapy. Data also suggest that patients older than 30 years who present with no neurologic deficit Clinical are more likely to benefit from lumbar traction. Tips Traction may relieve the patient’s symptoms in a disc lesion in the cervical spine and lumbar, during the acute phase, sustained traction should be no longer than 10 minutes and intermittent traction no longer than 15 minutes in duration. Motorized Pneumatic Weighted Autotractive Positional Inverted Manual Summery and Questions Thank you!