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

Therapeutic Exercise II PTA 1010 Spine part 2 (Posture) © Stanbridge University 2022 1  Objectives Describe normal and abnormal postures Recognize common pain syndromes related to impaired posture in each of the spinal regions Recognize the interactive role of inert, dynami...

Therapeutic Exercise II PTA 1010 Spine part 2 (Posture) © Stanbridge University 2022 1  Objectives Describe normal and abnormal postures Recognize common pain syndromes related to impaired posture in each of the spinal regions Recognize the interactive role of inert, dynamic, and neurological structures on spinal stability Differentiate b/w the role of global and segmental muscle activity on stabilization of the spine at all levels © Stanbridge University 2022 2 Objectives Instruct patients in programs to improve postural alignment both in static and dynamic functional activities Appropriately implement an exercise program for individuals with conditions affecting the spine Assist patients to develop healthy exercise habits using ergonomics, body mechanics, stress management, and relaxation techniques to prevent spinal injuries © Stanbridge University 2022 3 OUTLINE Posture and related pain Spinal Stability syndromes Generalized Guidelines for Management if Spinal Impairments © Stanbridge University 2022 4 Posture and Pain Syndromes © Stanbridge University 2022 5  What defines “Good Posture”? Slides 123- 132 is presenting a recent article discussing Posture, perceptions and its role in spinal dysfunction. This is a “hot topic” in the PT community currently. Some schools of thought feel posture is a major source of symptoms and other feel that poor postures are a normal part of life and not the main cause of pain and dysfunction. What do you think? © Stanbridge University 2022 6 © Stanbridge University 2022 7 © Stanbridge University 2022 8 © Stanbridge University 2022 9 © Stanbridge University 2022 10 © Stanbridge University 2022 11 © Stanbridge University 2022 12 © Stanbridge University 2022 13 © Stanbridge University 2022 14 © Stanbridge University 2022 15  Pain Syndromes Related to Impaired Posture There are 3 separate categories to describe pain created by postures © Stanbridge University 2022 16 Pain Syndromes Related to Impaired Posture 1) Postural Fault: posture that deviates from normal alignment but has NO structural impairments ie. Slouching in chair for 5 minutes 2) Postural Pain Syndrome: pain resulting from mechanical stress from maintaining a faulty posture for a prolonged period of time Pain is usually relieved with activity No impairments in strength or flexibility (yet) ie. Sitting in an airplane for a 5-hour flight to east coast © Stanbridge University 2022 17 Pain Syndromes Related to Impaired Posture 3) Postural Dysfunction: due to prolonged poor posture or as a result from adhesions formed following trauma or surgery. Includes adaptive shortening of soft tissues and muscle weakness Examples: Pt. who suffered a stroke sitting and slouching in a wheelchair for weeks Pt. who had a total knee replacement who does not work on ROM exercises and has a knee flexion contracture (cannot extend knee) © Stanbridge University 2022 18 Common Faulty Postures: Characteristics and Impairments Pelvic and lumbar region: lordotic, slouched, flat back postures Cervical and thoracic region: forward head & kyphotic, and flat upper back & neck postures Frontal plane deviations: Scoliosis and lower extremity asymmetries © Stanbridge University 2022 19  Dutton Figure 14.18 A: Lordotic Posture B: Relaxed or Slouched Posture: “Swayback” C: Flat Low Back posture D: Flat Upper Back and C/S © Stanbridge University 2022 20  Lordotic Posture Increased: Lordosis Anterior pelvic tilt Hip flexion Often seen with: Increased thoracic kyphosis Forward head © Stanbridge University 2022 21 Lordotic Posture: Impairments Mobility Impairment: Hip flexors (iliopsoas, TFL, rectus femoris) Lumbar extensors (erector spinae) Impaired Muscle Performance: Weak and stretched: abdominals Incl: rectus abdominis, internal & external obliques, transversus abdominis © Stanbridge University 2022 22 Lordotic Posture: Source of Symptoms Stress to and potential pain (Passive structures): Anterior longitudinal ligament (ALL) Narrowing of posterior disc, intervertebral foramen Compression of nerve roots in L/S Approximation of facets in L/S © Stanbridge University 2022 23 Lordotic Posture: Common Causes Sustained faulty posture Pregnancy Obesity Weak abdominals © Stanbridge University 2022 24 Relaxed and Slouched Posture: “Swayback” Standing: Shift of of entire pelvis segment anteriorly Hip extension Shift of thoracic segment posteriorly Thoracic flexion Lumbar lordosis OR posterior tilt w/ flattening of low lumbar area) Forward head © Stanbridge University 2022 25 Relaxed and Slouched Posture: Standing “Swayback” Mobility Impairments: Upper portion of rectus abdominus, upper fibers of internal oblique Intercostals Hip extensors Lower lumbar extensors (if lordotic) Impaired Muscle Performance: Weak & elongated lower rectus abdominus, external oblique, extensor muscles of the lower T/S, hip flexors, neck flexors © Stanbridge University 2022 26 “Swayback”: Source of Symptoms Stress and POTENTIAL PAIN to: Ilio-femoral ligaments Anterior longitudinal ligament: lower lumbar spine (if lordotic) Posterior longitudinal ligament upper lumbar, thoracic spine Lower lumbar spine: Narrowing of the intervertebral foramen and approximation of the facets © Stanbridge University 2022 27 “Swayback”: Common Causes Fatigue Attitude Weakness Poorly designed exercise program (emphasizes thoracic flexion) © Stanbridge University 2022 28 Flat Low Back Posture Decreased lumbar lordosis Hip extension Posterior tilt of the pelvis Often accompanied by forward head posture with slight C/S extension © Stanbridge University 2022 29 Flat Low Back Posture Mobility Impairments Trunk flexors: rectus abdominis, intercostals Hip extensors Muscle Performance Impairments: Weak and stretched: lumbar extensors, possible hip flexors © Stanbridge University 2022 30 Flat Back Posture: Source of Symptoms & Common Causes Source of Symptoms/pain: Decreased shock absorption (lack normal lumbar curves) Posterior longitudinal ligament Increased posterior disc pressure Common Causes: slouching, over-emphasis on flexion exercises © Stanbridge University 2022 31 Relaxed and Slouched Posture: Sitting bostonherald.com Sitting: Thoracic kyphosis, lumbar flexion, posterior pelvic tilt © Stanbridge University 2022 32 Round Back: Increased Kyphosis with Forward Head Increased T/S kyphosis Protracted scapula Forward head: increased flexion of the lower C/S and upper T/S; increased extension of the occiput on C1 Possible TMJ dysfunction: retrusion and depression of mandible Alexander.ie © Stanbridge University 2022 33 Round Back: Impairments Mobility Impairments: Muscle tightness intercostals pectoralis major and minor latissimus dorsi serratus anterior levator scapulae SCM Scalene Upper Trapezius muscles of the suboccipitals © Stanbridge University 2022 34 Round Back: Impairments Muscle Performance Impairments: Stretched and weak lower C/S and upper T/S erector spinae scapular retractors (rhomboid, middle trapezius) anterior throat (suprahyoid and infrahyoid) capital flexors (rectus capitus anterior and lateralis, longus colli and longus capitis) © Stanbridge University 2022 35  Figure 16.1 Kisner B. Pectoralis Major Stretch C A. T/S Mobility © Stanbridge University 2022 36 Round Back: Source of Symptoms/ pain ALL: upper C/S PLL and ligamentum flavum: lower C/S, T/S Muscle fatigue: T/S erector spinae, scapular retractors Facet joint irritation: upper C/S Upper C/S: narrowing intervertebral foramen TOS: impingement of neurovascular bundle form anterior scalene, pectoralis minor tightness © Stanbridge University 2022 37 Round Back: Source of Symptoms/pain Impingement of cervical plexus from levator scapulae tightness Impingement of the greater occipital nerves from tight or tense upper trapezius TMJ pain: mandibular mal-alignment, facial muscle tension Lower C/S disc lesions from the faulty flexed posture © Stanbridge University 2022 38 Round Back: Common Causes Slouching, poor ergonomic set up at work or home Sustained occupational or functional postures Over-emphasis on flexion exercises in a general exercise program © Stanbridge University 2022 39 Flat Upper Back & Neck Posture Decreased T/S curve Depressed scapula Depressed clavicles Decreased C/S lordosis with increased flexion of the occiput on the atlas © Stanbridge University 2022 40 Flat Upper Back and Neck Posture: Impairments Mobility Impairments: anterior neck muscles, T/S erector spinae, scapular retractors Muscle Performance Impairments: scapular protractors, anterior thorax intercostal muscles © Stanbridge University 2022 41 Flat Upper Back and Neck Posture: Sources of Symptoms uncommon postural deviation Postural muscle fatigue Compression of the neurovascular bundle in the TOS b/w the clavicle and ribs TMJ pain; changes in occlusion (bite) Decreased shock absorption in the spine due to loss of normal curve of the spine © Stanbridge University 2022 42 Scoliosis “Lateral Curvature of the Spine” 1.Structural Scoliosis: irreversible lateral curvature with fixed rotation of the spine; does not change with side bending 2. Non-structural Scoliosis: reversible by changing position, no significant rotation with lateral curve (also called: functional or postural scoliosis) © Stanbridge University 2022 43 Structural Scoliosis “C” or “S” Curve Curve is labeled by CONVEX side Rotation of vertebral bodies TOWARD the convexity of the curve Thoracic Spine: Rib prominence posteriorly on the side of the convexity (in picture- right rib hump) orthoinfo.aaos.org Rib prominence anteriorly on the side of the concavity © Stanbridge University 2022 44  STRUCTURAL SCOLIOSIS A: Mild right thoracic, left B: Forward flexion: sight lumbar scoliosis, prominence posterior rib hump (fixed of the right scapula rotation of the vertebra and ribs) Figure 14.19 Kisner & Colby 5th edition © Stanbridge University 2022 45 Example: Right C curve scoliosis RIGHT convexity RIGHT Rib Hump RIGHT Rotation Left Concavity www.orthoinfo.aaos.com © Stanbridge University 2022 46 Example: Left scoliosis LEFT convexity Left side LEFT posterior rib hump LEFT Rotation Right Concavity Right side www.jaoa.org © Stanbridge University 2022 47 Structural Scoliosis: Common Causes Neuromuscular Disease: cerebral palsy, spinal cord injury, progressive diseases Osteopathic Disorders: osteomalacia, rickets, fractures Idiopathic Disorders: “Unknown” © Stanbridge University 2022 48 Nonstructural Scoliosis: Common Causes Leg length discrepancy can cause both -Structural -Functional Muscle guarding due to pain Habitual or asymmetrical postures © Stanbridge University 2022 49 Management of Impaired Posture 1.Postural Training Techniques Goal is to create kinesthetic awareness correction caudal → cranial Verbal/tactile/visual reinforcement of proper alignment External support: i.e., bracing 2.Flexibility exercises 3.Strength and endurance training Box 14.1 © Stanbridge University 2022 50 Management of Impaired Posture 4. Teach proper body mechanics 5. Proper Ergonomic Set –Up (www.osha.gov/SLTC/ergonomics/) 6. Stress Management/Relaxation Muscle Relaxation Techniques Conscious Relaxation Techniques Modalities and Massage 7. Healthy Exercise Habits © Stanbridge University 2022 51  Muscle Relaxation Techniques Discomfort from a Particular Posture or Position: Perform AROM in the OPPOSITE direction of the postural dysfunction -takes stress off supporting structures -promotes circulation -maintains flexibility Perform all motions SLOWLY, through full available ROM Do throughout the day for several repetitions © Stanbridge University 2022 52 Muscle Relaxation Techniques Cervical and Upper Thoracic Spine Forward, Backward bending Side bend each way Rotate each way Roll shoulders: protract, elevate, retract scapula Shoulder circumduction: arm circles – clockwise and counterclockwise © Stanbridge University 2022 53 Muscle Relaxation Techniques Lower Thoracic and Lumbar Spine Extension Flexion Side bend each way Rotation each way (thoracic) Stand and walk at regular intervals throughout the day if have a sitting job © Stanbridge University 2022 54 OUTLINE Posture and related pain Spinal Stability syndromes Generalized Guidelines for Management of Spinal Impairments © Stanbridge University 2022 55 Spinal Stability © Stanbridge University 2022 56  Spinal Stability Provided by 3 subsystems: 1. Passive System: inert structures/bones & ligaments 2. Active System: muscles 3. Neural Control System If any one of these three systems is not providing support → affects stability of the whole structure journals.humankinetics.com © Stanbridge University 2022 57 Spinal Stability Instability is often the result of a combination of: 1.Inert tissue damage (ligaments, discs, etc) Table 14.2- Stabilizing Features of Inert Tissues in the Spine 2.Insufficient muscular strength and endurance 3.Poor neuromuscular control © Stanbridge University 2022 58 Spinal Stability: Active Subsystem There is NO SINGLE MUSCLE that is the best stabilizer of the spine ALL MUSCLES WORK TOGETHER to create stiffness/ stability in all motions McGill et al 2003 Journal of Electromyography and Kinesiology © Stanbridge University 2022 59 Spinal Stability: Muscles Superficial (Global) Muscles: only able to stabilize through COMPRESSION- not optimal Little or no direct attachment to the vertebra Far from the axis of motion Deep (Segmental) Muscles: have DIRECT ATTACHMENT across the vertebral segments Provide dynamic support to individual segments of the spine Maintain each segment in a stable position © Stanbridge University 2022 60 Global (Superficial) Muscle Function A: Guy wire function provides overall stability B: Cannot control multi-segmental spine: compressive loading from long guy wires leads to stress on inert tissues at the end ranges of the unstable segment Fig 14.8 © Stanbridge University 2022 61 Deep/Segmental Muscle Function Attached to each spinal segment provide dynamic support to EACH segment Close to axis of motion Greater % of Type I fibers: increased endurance Fig 14.9 © Stanbridge University 2022 62 Muscles- Lumbar Region Table 14.4 pg 418 Global Muscles Segmental Muscles Rectus abdominis Transverse Abdominis External and Internal obliques Multifidi Quadratus lumborum (lateral Quadratus lumborum (deep portion) portion) Erector spinae (iliocostalis, Deep rotators (intersegmental longissimus, spinalis) rotators, intertransversarii) Iliopsoas *Not identified in same categories in research articles © Stanbridge University 2022 63 Spinal Stability- Anterior Kisner Figure 14.11 Lumbar region: TL fascia and relationship to muscles in the region © Stanbridge University 2022 64 Spinal Stability- Posterior Thoracolumbar Fascia Muscles of the Back (Fig 14.2) (Fig 14.3) © Stanbridge University 2022 65 Muscles- Cervical Region Global Muscles Segmental Muscles Sternocleidomastoid Rectus capitis anterior Longus Scalenes capitis Anterior, middle, posterior Longus colli Levator scapulae Multifidi Upper trapezius Erector spinae Iliocostalis Longissimus Spinalis © Stanbridge University 2022 66 Spinal Stability Role of Muscle Endurance: Postural muscles- higher % of Type I fibers than other types (IIA, IIB) Inactivity: changes fiber composition and size → decreased muscle endurance during sustained or repetitive activities → decreased function in patients with low back pain→↑ fatty infiltrates in muscle Inactivity can be caused by avoidance patterns (conscious and subconscious) © Stanbridge University 2022 67 Multifidi brentbrookbush.com coreconcepts.com.sg © Stanbridge University 2022 68 Multifid Atrophy in the Lumbar spine researchgate.net © Stanbridge University 2022 69  Altered Multifidus Recruitment Smith et al. JOSPT, 2016 LBP studies have shown: Impaired timing (neural control) of the anticipatory activity (Feedforward) of the deep multifidus muscle in patients with low back pain. Decreased amplitude of activity (decreased strength of contraction) has been shown in asymptomatic individuals with previous low back pain in response to perturbations and voluntary flexion Participants with recurrent low back pain respond to increased mechanical demand by decreasing the duration of activation in the deep fibers of the multifidus. = Maladaptive behavior! © Stanbridge University 2022 70 Altered muscle recruitment- C/S Pain O’Leary et al, JOSPT 2009 C/S pain studies have shown: Changes in structure: Widespread atrophy, pseudo hypertrophy and fatty replacement of cervical extensor muscles Multifidi and semispinalis capitus muscles Changes (decreased) neural control: Heightened activity of superficial muscles (SCM and anterior scalene); decreased ability of UT and superficial cervical muscles © Stanbridge University 2022 71 Altered muscle recruitment- C/S Pain O’Leary et al, JOSPT 2009 C/S pain studies have shown: Changes in (decreased) strength: Changes in endurance, precision and efficiency noted at intensities typical of ADLs Decreased ability to generate torque Changed afferent input from neck muscles can affect eye gaze stability and orientation of head in space © Stanbridge University 2022 72 Spinal Stability: Neurological Control Why is Neurological control important? 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 Feedforward control (anticipatory): Healthy control includes postural responses of trunk muscles preceding limb muscle movement © Stanbridge University 2022 73 Spinal Stability: Effects of Limb Function Without stabilization of the spine, contraction of the limb-girdle musculature would transmit forces proximally creating excessive stress on the spinal structures and supporting soft tissue Injury (Traumatic or Repetitive) Spine is injured under 20lbs of pressure © Stanbridge University 2022 74 Psychosocial Risk Fear avoidance- avoidance of movement or activities based on fear can also affect neuromotor control Can lead to deconditioning syndrome Fear avoidance model Use the Fear Avoidance Belief Questionnaire (FABQ) Indicates need for cognitive behavioral therapy Vlaeyen et al, Pain, 2000 © Stanbridge University 2022 75 Fear avoidance jpain.org © Stanbridge University 2022 76 Effects of Breathing on Posture and Stability Normal ventilation does not affect spinal stability Ventilatory system under stress Inspiration= increased stability Increased back extensor activation/back extension Function of: Intercostal muscles TrA- feed forward mechanism with diaphragm Expiration= decreased stability, back flexion Wang et al. Journal of Applied Biomechanics, 2008 © Stanbridge University 2022 77 Effects of Intra-abdominal Pressure and the Valsalva Maneuver Valsalva: Force expiration against a closed glottis During Valsalva there is co-contraction of TrA, IO and EO muscles Few theories on its affects: Unload compressive forces on the spine and increase stabilizing effect by pushing out abdominal muscles Prevents buckling of the spine DANGER: Can cause Rapid Changes in BP and HR ***Teach proper breathing with all exercise © Stanbridge University 2022 78 © Stanbridge University 2022 79 Spinal Stability: Passive Subsystem Inert Tissues: C/S facet orientation T/S facet orientation L/S facet orientation Ribs Spinous processes Intervertebral discs Ligaments Thoracolumbar fascia (has static & dynamic function) © Stanbridge University 2022 80 Segmental Instability Injury, hypomobility of another segment, degeneration or congenital defects can create segmental instability Poor control within the physiological range of spinal movement Pain often reproduced with: Aberrant movement at the segment Sustained position Stresses that the muscles can’t control © Stanbridge University 2022 81  Segmental Instability Neutral Spine: clinical term used to define mid-range of motion where patient is the most comfortable. Neutral Zone: area that is mid-range in the ROM of a spinal segment in which no stress is being placed on the passive osteoligamentous structures in the spine Outside of neutral zone (R1-R2) structures are stressed Excessive stress→ damage or pain © Stanbridge University 2022 82 Neutral Spine and Neutral Zone © Stanbridge University 2022 83 Spine Stability Assessment A simple MMT may not create a full picture of the function of the spine musculature Assess core muscle activation: cervical or lumbar spine Does the patient activate the correct muscles? Often tested via positional endurance tests © Stanbridge University 2022 84 Cervical Stability Examples Endurance Assessment These tests will be taught in TMT course Cranial cervical flexion test Neck flexor muscle endurance Deep neck extensor endurance test © Stanbridge University 2022 85 Lumbar spine Stability Assessment Examples Side support endurance-1 min minimum SL bridge x 10 each side Pts categorized as “No, slight, moderate or accentuated pelvic tilt” Prone hip rotation Positive test: lumbar motion, should be able to isolate hip Supine hip abduction Positive test: lumbar motion, should be able to isolate hip Prone knee flexion (tightness of rectus femoris) Multifidus Lift Test (palpate at L4-5 or L5-S1) © Stanbridge University 2022 86 Stabilization Exercises Stabilization exercises should not create more flexion or extension of the spine from initial starting position if performed correctly Often referred to “anti-rotational” exercises The muscles that create spinal rotation are used isometrically to prevent the spine from rotating as the limbs are loaded © Stanbridge University 2022 87 Stabilization exercises Perform stability exercises in: Neutral spine If the patient cannot be in neutral spine without pain, move to a position without pain Functional spine As close to neutral spine as possible without symptoms (either into some flexion or extension based on directional preference) © Stanbridge University 2022 88 A C/S Stabilization Exercises: Training of the Deep Flexors 10x10” © Stanbridge University 2022 89 A Supine C/S Stabilization Exercises Deep C/S Flexors with Global UE 20-30 reps or 1 min © Stanbridge University 2022 90 A Prone C/S & Scapular Stabilization Exercises C/S deep flexors, global extensor bias (pillows under trunk, small towel roll under forehead) 20-30 reps or 1 min © Stanbridge University 2022 91 A Figure 16.46 Kisner Progression on Unstable Surfaces 20-30 reps or 1 min Once control on stable surfaces is demonstrated then you can move the patient to more functional positions on unstable surfaces © Stanbridge University 2022 92 Okubo et al JOSPT 2010 Compared: Elbow toe, with and w/o opp UE/LE lift, Quadruped with opp UE/LE lift, Bridge with and w/o LE leg lift, Side bridge with and w/o LE abd, Curl up (Crunch) © Stanbridge University 2022 93 Trunk Muscle Highest Level of Activity Okubo et al JOSPT 2010 Transverse Abdominis (TraA): elbow-toe plank with arm and leg lift (Abdominal hallowing still higher) R TrA- plank with R arm and left leg lift Multifidus: Back bridge with leg lift Strong activation bilaterally Rectus Abdominis: Curl up (crunch) External Oblique (EO): elbow-toe plank R EO: left arm and right leg Erector Spinae (ES): Back bridge with leg lift © Stanbridge University 2022 94  Figure 16.48 Kisner A Basic Abdominal Stabilization Progression: Supine TrA and Multifidus activation with global flexors. Start: 20-30 reps or 1 min © Stanbridge University 2022 95  Figure 16.5 Kisner A Stabilization Exercises in Quadruped: Rod giving tactile feedback TrA and Multifidus with Global lumbar & hip extensors &UE. Start 20-30 reps or 1 min © Stanbridge University 2022 96 A Basic Stabilization Progression for Core and the global Lumbar Extensors Can then add in UE movements, double leg lifts, etc. Consider use of pillows under trunk if hip flexors are tight (hip flexion contracture) Start 20-30 reps or 1 min Physera.com © Stanbridge University 2022 97  Review What is spondylolisthesis? What bias do we treat Anterolisthesis? Retrolisthesis? What are various exercises that can be used to treat this pathology? How do we treat segmental instability? How does changes in the control subsystem vs active or passive subsystems affect the prognosis (the pts capability to get better) of the patient? What exercises can we use? When would be choose flexion or extension stabilization biased exercises? © Stanbridge University 2022 98 Review What are the 3 subsystems for spinal stability and how do they contribute to stability? What are the main global and deep segmental muscles of the torso? How do the global muscles contribute to stability? What is the Valsalva maneuver and what are the potential dangers of using this technique? © Stanbridge University 2022 99 OUTLINE Posture and related pain Spinal Stability syndromes Generalized Guidelines for Management if Spinal Impairments © Stanbridge University 2022 100 Generalized Guidelines for Management if Spinal Impairments © Stanbridge University 2022 101 General Guidelines for Managing Spinal Impairments Acute Phase: Patient Education Teach positions of symptom relief/comfort: i.e. NWB, extension, or flexion bias’, etc. Kinesthetic Awareness Training Muscle Performance Training Basic Functional Movement Training © Stanbridge University 2022 102 General Guidelines for Managing Spinal Impairments Kinesthetic Awareness Training: teach awareness of safe postures and the effects of movement Muscle Performance Training: Deep Segmental Muscle Activation and Basic Stabilization: teach patient how to activate deep segmental muscles (of C/S or L/S) and then superimpose UE and LE movements on a stable spine Basic Functional Movement Training: perform simple movements for ADL’s while protecting the spine © Stanbridge University 2022 103 General Guidelines for Managing Spinal Impairments Subacute/Controlled Motion Phase: Patient education Pain modulation Kinesthetic training Stretching/manipulation Muscle performance training Cardiopulmonary conditioning Postural stress management/relaxation exercises Functional activities: proper body mechanics © Stanbridge University 2022 104 Once patient can stabilize in neutral →Begin with limb loading progressions in the position consistent with their directional preference Flexion Biased Extension Biased Stenosis/ anterior spondylolisthesis, Posterior HNP, Retro-spondylolisthesis facet dysfunction (rare) Cervical spine: supine Cervical spine- prone Lumbar spine: supine in hook- Lumbar spine- start in quadruped, lying progress to prone lying © Stanbridge University 2022 105 PRE for Trunk Stability Arm Pull Down, Bridge up, Bridge Unsupported Abdominal Stabilization down, Arms Up © Stanbridge University 2022 106 PRE for Trunk Stability Abdominal Curls: Arms in Extension Holds front, across chest, behind head © Stanbridge University 2022 107 PRE for Trunk Stability Bridge with Alternating Leg March, Knee Ext. Ball Walk Out to Push Up © Stanbridge University 2022 108 PRE for Trunk Stability Side Plank: on elbow, on hand Unstable Surfaces © Stanbridge University 2022 109 PRE For stability- standing loads © Stanbridge University 2022 110 Spinal stability standing progressions © Stanbridge University 2022 111 General Guidelines for Managing Spinal Impairments Chronic/ Return to Function Phase: Progressions Return-to-work programs “Work Hardening” Graduated Return-to-Play/Sport programs Conditioning programs High intensity, Repetitive programs © Stanbridge University 2022 112 General Guidelines for Managing Spinal Impairments Return to Function Phase: Repetitive lifting Repetitive reaching Repetitive pushing and pulling Rotation or turning activities Transitional movements Transfer of training © Stanbridge University 2022 113 Cardiopulmonary Endurance Goal: increase cardiopulmonary endurance to enhance overall well being and relief of symptoms Choice of modality depends on if a particular spinal bias has been identified (flexion vs. extension vs. neutral position) Program: -Warm Up -Exercise -Cool Down © Stanbridge University 2022 114 Common Aerobic Exercises and Effects on the Spine Analyze the biomechanics of an exercise type to pick the best type for specific diagnosis (based on directional preference) Cycling Walking and running Stair climbing Cross-country skiing, ski machines, and swimming Upper body ergometer machines Step aerobics and aerobic dancing The“latest popular craze” © Stanbridge University 2022 115 Did we meet these Objectives? Understand tempo-mandibular joint dysfunction Describe normal and abnormal postures Recognize common pain syndromes related to impaired posture in each of the spinal regions Recognize the interactive role of inert, dynamic, and neurological structures on spinal stability Differentiate b/w the role of global and segmental muscle activity on stabilization of the spine at all levels © Stanbridge University 2022 116 Did we meet these Objectives? Instruct patients in programs to improve postural alignment both in static and dynamic functional activities. Appropriately implement an exercise program for individuals with conditions affecting the spine. Assist patients to develop healthy exercise habits using ergonomics, body mechanics, stress management, and relaxation techniques to prevent spinal injuries. © Stanbridge University 2022 117 References Stuart M McGill, Sylvian Genier, Natasa Kavcic and Jacek Cholewicki, Coordination of muscle activity to assure stability of lumbar spine. Journal of Electromyography and Kinesiology 2003; 13: 353-359 Simon Wang and Stuart M McGill, Links between the mechanics of ventilation and spine stability, Journal of Applied Biomechanics, 2008; 24:166-174 Shaun O’Leary PT, PhD, Deborah Falla, PT, PhD, James M. Elliott, PT, PhD, Gwendolen Jull, PT, PhD, Muscle dysfunction in cervical spine pain, JOSPT 2009; 39(5): 324-333 Callahan JP and McGill SM, Intervertebral disc herniation: Studies on porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinic Biomech 2001: 16: 28-37 Muhammad Alrwaily, Michael Timko, Michael Schneider, Joel Stevans, Christopher Bise, Karthik Hariharan, Anthony Delitto, Treatment- Based Classification System for Low Back Pain: Revision and Update, Physical Therapy 2016, 96 (X): 1-10 Johan W.S. Vlaeyan and Steven J Linton. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of art. Pain 2000; 85: 317-332 Jo Armour Smith and Kornelia Kulig, Altered multifidus recruitment during walking in young asymptomatic individuals with a history of low back pain. Physical Therapy 2016; 46(5): 365-374 © Stanbridge University 2022 118 References John D Childs, Joshua Cleland, James M Elliott, Deydre S teyhen, Robert S Wainner, Julie M Whitman, Bernard J Sopky, Joseph J Godges, Timothy W Flynn, Neck Pain: Clinical Practice Guidelines linked to the international classification of functioning, disability, and health from the Orthopedic Section of the American Physical Therapy Association, JOSPT 2008, 38(9): A1-A34 Anthony Delitto, Steven A George, Linda Van Dillen, Julie M Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R Derringer, Joseph J Godges, Low back pain: Clinical Practice Guidelines linked to the international classification of functioning, disability, and health from the Orthopedic Section of the American Physical Therapy Association, JOSPT 2012; 42(4):A1-A57 Shaun O’Leary, Deborah Falla, James M Elliott, Gwendolen Jull, Muscle dysfunction in cervical spine pain: Implications for assessment and management. JOSPT 2009; 39(5): 324-333 Yu Okubo, Koji Kaneoka, Atsushi Imai, Itsuo Shina, Masaki Tatsumura, Shumpei Miyakawa, Electromyographic analysis of Transverse Abdominis and Lumbar Multifidus using wire electrodes during lumbar stabilization exercises, JOSPT 2010, 40(11): 743-750 Peter Blanpied, Anita Gross, James Elliott, Laurie Devaney, Derek Clewley, David Walton, Cheryl Sparks, Eric Robertson, Neck Pain: Revision 2017 Clinical Practice Guidelines linked to the international classification of functioning, disability and health from the orthopedic section of the American Physical Therapy Association, JOSPT 2017, A1-A83 © Stanbridge University 2022 119