Lumbar Segmental Instability Spring 2024-2025 PDF

Lumbar segmental instability ASHOKAN ARUMUGAM, PHD (PT), MPT ASSOCIATE PROFESSOR DEPARTMENT OF PHYSIOTHERAPY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF SHARJAH Spinal Stability “Stability” is defined as “the effective accommodation of the joints to each specific load demand through an adequately tai...

Lumbar segmental instability ASHOKAN ARUMUGAM, PHD (PT), MPT ASSOCIATE PROFESSOR DEPARTMENT OF PHYSIOTHERAPY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF SHARJAH Spinal Stability “Stability” is defined as “the effective accommodation of the joints to each specific load demand through an adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to produce effective joint reaction forces under changing conditions” (Vleeming et al., 2008) Clinical stability The spine’s ability under physiologic loads to limit patterns of displacement in order not to damage or irritate the spinal cord and nerve roots and to prevent incapacitating deformity or pain caused by structural changes It is also the capacity of the vertebrae to remain cohesive and to preserve the normal displacements in all physiological body movements  For each of the six degrees of freedom of motion, any vertebra can perform with respect to other vertebrae has its own range of motion (ROM).  The physiologic range of motion (ROM) includes a neutral zone (NZ) and an elastic zone (EZ).  The NZ is the initial part of the intervertebral motion on either side of the neutral position where it meets relatively low resistance and the spine exhibits high flexibility owing to the laxity status of capsules, ligaments and tendons.  The NZ is followed by the EZ where the resistance to movement increases when the ligaments, capsules, fasciae and tendons are subjected to tension requiring more load per unit displacement. When three-dimensional motion occurs between objects, a unique axis in space is defined called the helical axis of motion (HAM), or screw axis of motion (Figure 2-18). HAM is the most precise way to describe motion occurring between irregularly shaped objects, such as anatomic structures, because it is difficult to consistently and accurately identify reference points for such objects. Coupled motions  Coupling is defined as the consistent association of one motion about an axis with another motion around a different axis.  The most predominant motions that exhibit coupled behaviors are lateral flexion and rotation.  Pure lateral flexion and pure rotation do not occur in any region of the spine.  In order for either motion to occur, at least some of the other must occur as well. Fryette's laws * law 1 and 2 applies to both thoracic and lumbar spine * law 3 applies to the entire spine LAW 1 - when the spine is in neutral, side-bending to one side will be accompanied by horizontal rotation to the OPPOSITE side --> coupled motion LAW 2 - when the spine is in flexed/extended position (non-neutral), side-bending to one side will be accompanied by rotation to the SAME side LAW 3 - when the motion in introduced in one plane, it will modify (reduce) motion in the other two planes --> non coupled law 3 basically means that if there is motion in one plane for example, flex or ext, the motion in another plane won't happen (side bending or rotation) Spinal instability Damage to any spinal structure gives rise to some degree of instability. The loss of stability, (instability) is an important, often unknown, cause of back pain particularly at the lumbar level. With instability, movement can be abnormal in quality (abnormal coupling patterns) and/or quantity (increased motion) In asymptomatic subjects, the neural zone (NZ) and ROM are normal and contained within the limits of the pain free zone (PFZ). The NZ is thought to increase over the PFZ limits in an unstable spine. Muscular training and surgical fusion improve spinal stiffness reducing the NZ and freeing the spine from the symptoms of instability.. These three systems are considered to work synergistically to establish optimal stability, mobility and neuromuscular performance of the lumbopelvic segments during gait and other activities (Lee, 2004; Vleeming et al., 2007). Passive Stabilization The intrinsic structural role and passive stabilization of the spine depend on:  Vertebral architecture and bone mineral density,  Disc-intervertebral joints,  Facet joints,  Ligaments, and  Physiological curves. Bones, disks and ligaments contribute by playing a structural role and by acting as transducers through their mechanoreceptors. Mechanoreceptors send proprioceptive impulses to the central nervous system which coordinates muscle tone, movement and reflexes. Active stabilization  Muscles and tendons provide active stabilization of the spine under the control of the nervous system, ensuring stability primarily in the NZ where the resistance to movement is minimal. Neuromuscular control   Neuromuscular control is defined as the involuntary activation of dynamic restraints in preparation for (feedforward) and/or in response to (feedback) joint motion and loading, thereby maintaining and restoring joint stability under functional demand (Riemann and Lephart, 2002) Neuromuscular control is how your muscles and nerves work together to keep your joints stable. Feedforward control: Your body prepares muscles in advance before movement (e.g., tightening your core before lifting something heavy). Feedback control: Your body adjusts muscles in response to movement or load (e.g., correcting balance if you trip). This helps maintain stability and prevent injuries during activities. Lumbar segmental instability  A significant subgroup within the chronic low back pain population  Loosening of the motion segment secondary to injury and associated dysfunction of the local muscle system, and intervertebral disc degeneration  Spinal segmental instability A significant decrease in the capacity of the stabilizing systems of the spine to maintain intervertebral neutral zones within physiological limits so there is no major deformity, neurological deficit or incapacitating pain. Clinical patterns Based on –  Directional nature of injury  Patients symptoms  Motor dysfunction Four clinical patterns –  Flexion  Extension  Lateral-shift  Multidirectional Symptoms common to all patterns  Vulnerability and observed lack of movement control and related symptoms in the neutral zone  Inability to initiate co-contraction of the local muscle system within the zone  Compensatory movement strategies which stabilize the motion segment out of the neutral zone and towards an end-range position (such as flexion, lateral shift or extension) Flexion pattern  Most common  Central back pain  Single or repeated flexion/rotation injuries/ movements  Loss of segmental lumbar lordosis  An arc of pain into flexion and an inability to return from flexion to neutral without use of the hands to assist the movement Extension pattern  Single or repeated extension/rotation injuries/movements  An increase in segmental lumbar lordosis  Extension reveals segmental hinging in the affected segment with a loss of segmental lordosis above this level (postural sway)  Lumbar flexion – a tendency to hold the lumbar spine in lordosis with a sudden loss of lordosis in the midrange flexion associated with an arc of pain  Returning to neutral with the use of the hands to assist the movement with a tendency to hyperlordose the spine segmentally before the upright posture upper abdomen is flat lower abdomen is bulging lower cross syndrome --> lumbar extensors and hip flexors are tight lower abdomen and glut maximus are weak Lateral shift pattern  A vulnerability to reaching or rotating in one direction associated with flexed postures  This is the same movement direction that they report `injuring' their back.  They present in standing with a loss of lumbar segmental lordosis at the affected level but with an associated lateral shift at the same level.  Palpation of the lumbar multifidus muscles in standing commonly reveals resting muscle tone on the side ipsilateral to the shift, and atrophy and low tone on the contra-lateral side.  Sagittal spinal movements reveal a shift further laterally at mid range flexion and this is commonly associated with an arc of pain.  This is associated with bracing of the abdominal wall and loss of breathing control. bipedal to unipedal stance there is compensation of trunk bec the patient cannot shift weight through lumbar spine Multi-directional pattern  Most serious and debilitating  Associated with a traumatic injury and high levels of pain and functional disability  All weight bearing postures are painful  Difficulty in obtaining relieving positions during weight bearing  Locking of the spine is following sustained flexion, rotation and extension postures  ‘Jabbing’ pain and associated back muscle spasm  Palpatory examination reveals multi-directional increased intersegmental motion at the symptomatic level. Aims of the physical examination 1. Identify the symptomatic hypermobile motion segment and correlate this with radiological findings if present 2. Identify the clinical pattern 3. Determine the neuro-muscular strategy of dynamic stabilization  observe for loss of dynamic trunk stabilization during functional movement  identifylocal muscle system dysfunction and faulty patterns of global muscle system substitution  determinethe relationship between symptoms and local muscle system control Lumbar Movement Control Dysfunction Screening  https://www.youtube.com/watch?v=usvVumUTTtw  https://www.youtube.com/watch?v=OrgoC3mKhXQ  https://www.youtube.com/watch?v=A4gU0YD6HS4 MANAGEMENT OF LUMBAR SEGMENTAL INSTABILITY  The provision of dynamic stability and segmental control to the spine i.e. transversus abdominis, diaphragm and lumbar multifidus, based on the identification of specific motor control deficits in these muscles https://dianeleephysio.com/education/core-training-vs-strengthening/ First stage of training  The cognitive stage - a high level of awareness is demanded in order that they isolate the co- contraction of the local muscle system without global muscle substitution. https://www.youtube.com/watch?v=O0bMUrzZxAA  To train the specific isometric co-contraction of transversus abdominis with lumbar multifidus at low levels of maximal voluntary contraction and with controlled respiration, in weight bearing within a neutral lordosis. Second stage of training  The second phase of motor learning is the associative stage, where the focus is on refining a particular movement pattern.  The aim is to identify two or three faulty and pain provocative movement patterns based on the examination and break them down into component movements with high repetitions (i.e., 50 ± 60).  The patients carry out the movement components on a daily basis with pain control and gradually increase the speed and complexity of the movement pattern until they can move in a smooth, free and controlled manner.  Patients are encouraged to carry out regular aerobic exercise such as walking while maintaining correct postural alignment, low level local muscle system co-contraction and controlled respiration. This helps to increase the tone within the muscles and aids the automaticity of the pattern.  Patients are encouraged to perform the co- contractions in situations where they experience or anticipate pain or feel `unstable'. This is essential, so that the patterns of co-contraction eventually occur automatically.  This stage can last from between 8 weeks to 4 months depending on the performer, the degree and nature of the pathology and the intensity of practice, before the motor pattern is learned and becomes automatic. Third stage of training  The autonomous stage where a low degree of attention is required for the correct performance of the motor task  The Cluster of Rehorst | Lumbar Segmental Instability https://www.youtube.com/watch?v=usvVumUTTtw  Prone Instability Test | Lumbar Spine Instability https://www.youtube.com/watch?v=OrgoC3mKhXQ  Lumbar Motor Control Impairment (MCI) | Symptoms, Assessment and Diagnosis- https://www.youtube.com/watch?v=9uns1OrBUG8&list=PLO_peL93VBmlQuSYrCQutFiqqTDg UByxK  Luomajoki Lumbar Movement Control Dysfunction Screening https://www.youtube.com/watch?v=A4gU0YD6HS4  Lumbar Spine Local Stabilizers Assessment | Pressure Biofeedback Unit https://www.youtube.com/watch?v=O0bMUrzZxAA  Core training versus strengthening https://dianeleephysio.com/education/core-training-vs-strengthening/  O'Sullivan, P. B. (2000). Lumbar segmental instability': clinical presentation and specific stabilizing exercise management. Manual therapy, 5(1), 2-12.  Luomajoki, H., Kool, J., De Bruin, E. D., & Airaksinen, O. (2007). Reliability of movement control tests in the lumbar spine. BMC musculoskeletal disorders, 8(1), 1-11.  Thank you Any Questions!