Physical Therapy for Lumbar Spine - Part 1 PDF

PHYSICAL THERAPY FOR LUMBAR SPINE PART 1 By / Bishoy Lobbos OBJECTIVES By the end of this lecture, the student should be able to:  Memorize the related clinical anatomy.  Memorize the related clinical biomechanics.  Define low back pain syndrome.  Describe the path...

PHYSICAL THERAPY FOR LUMBAR SPINE PART 1 By / Bishoy Lobbos OBJECTIVES By the end of this lecture, the student should be able to:  Memorize the related clinical anatomy.  Memorize the related clinical biomechanics.  Define low back pain syndrome.  Describe the pathological based classification of LBP and common pathological condition.  Identify the red flags of lumbar spine.  Recognize the evidence (guidelines) based treatment of acute LBP.  Recognize and understand the treatment (impairment) based classification of LBP  CLINICAL ANATOMY  5 vertebrae  Each vertebra has body anteriorly and arch posteriorly.  Posterior arches together make spinal canal and intervertebral foramen  Intervertebral articulation by facet joint and intervertebral disc FACET JOINT  Synovial joint carry about 20% to 25% of the axial load, 70% with degeneration of the disc.  The superior facets face medially and backward and, in general, are concave; the inferior facets face laterally and forward and are convex INTERVERTEBRAL DISC  20% to 25% of the total length of the vertebral column.  shock absorber and allow movement between the bones.  ANNULUS FIBROSUS & NUCLEUS PULPOSUS  LIGAMENTS  Anterior longtudinal lig (limit EXT)  Posterior longtudinal lig (limit FLX)  ligamentum flavum (limit FLX)  supraspinous lig (limit FLX)  Interspinous lig (limit FLX)  Intertransverse lig ( limit contralateral S.B)  iliolumbar lig ( Stabilize L5/S1) MUSCLES  THE STABILIZING SYSTEMS OF THE SPINE  The Passive subsystem (ligaments, joint and bone) produces reactive forces by the end of the ranges of motion work as a signals transducer to the neural subsystem  The Active subsystem (muscles and tendons) generate forces to supply the stability to the spine  The Neural Control subsystem. receive all the sensory feedback from the transducers of the passive system, determine the stability requirements and make the active system to achieve those stability goals.  THE ACTIVE SUBSYSTEM  Global muscles.  Rectus abdominis, External and internal obliques, Quadratus lumborum (lateral portion), Erector spinae, Iliopsoas.  have little or no direct attachment to the vertebrae.  stabilize spinal segments through compressive loading.  Deep/segmental muscles  Transversus abdominis, Multifidus, Quadratus lumborum (deep portion), Deep rotators.  direct attachments across the vertebral segments, provide dynamic support to individual segments in the spine MULTIFIDUS AND TRANVSERSUS ABDOMIMIS  CLINICAL BIOMECHANICS Resting position: Midway between flexion and extension Close packed position: Full extension Capsular pattern: Side flexion and rotation equally limited, extension Coupling mechanism: In the lumbar spine, the movement of side bending is coupled with rotation. Because of the position of the facet joints, both side flexion and rotation occur together. According to Fryette, this coupling is contralateral in neutral and ipsilateral in flexed or extended posture FORWARD BENDING:  Inferior facet of superior vertebra glides up and forward onsuperior facet of inferior vertebra  Nucleus pulposus migrates posteriorly, annulus fibrosis bulges anteriorly  Spinal canal and intervertebral foramen lengthen and open BACKWARD BENDING.  Inferior facet of superior vertebra glides down and backward on superior facet of inferior vertebra  Nucleus pulposus migrates anteriorly, annulus fibrosis bulges posteriorly  Spinal canal and intervertebral foramen close  SIDE BENDING (RIGHT):  Inferior facet of superior vertebra upglides on left and downglides on right  Right intervertebral foramen closes, left intervertebral foramen opens  Coupled with contralateral ROT in neutral and ipsilateral ROT out of neutral ROTATION (RIGHT)  Inferior facets of superior vertebra open on right and closes on left  Right intervertebral foramen opens, left intervertebral foramen closes  Coupled with contralateral SB in neutral and ipsilateral SB out of neutral EFFECT OF POSTURE ON DISCAL PRESSURE  LOW BACK PAIN SYNDROME A clinical entity that is characterized by the occurrence or presence of one or more of the following signs or symptoms:  (1) pain in the area of the lumbosacral spine, buttock, or referred to the thigh area to the knee but thought to be of spinal origin.  (2) pain, paresthesia, or other changes in cutaneous sensation located in the leg or foot area but believed to be of spinal origin (radicular symptoms).  (3) alterations in reflexes or loss of motor function in the lower extremities, again from spinal origin (radicular signs).  PATHOLOGY BASED CLASSIFICATION  Without a specific diagnosis, the limitations of the traditional "pathology based model," which implies symptoms should be proportional to organ pathology  three basic questions should be answered during the initial clinic visit: (1)Is there systemic or visceral disease underlying the pain? (2) Is there evidence of neurologic compromise that represents a surgical emergency? (3) Are there findings that influence the choice of conservative therapies? Data from the history and physical examination presumably lead to answers to all three questions.  EXAMINATION  History  Palpation  Mobility tests. 1- active 2- passive 3- accessory intervertebral mobility  Neurological tests.  Stability tests.  Functional outcomes. The Oswestry Disability Index (ODI) Fear avoidance beliefs questionnaire (FABQ) PATHOLOGY BASED CLASSIFICATION VISCERAL  Kidney, ureter, pelvic organs, and intestines can causes causes referrred pain in the lumbar spine through the segmental irritation ( T12, L1, L2) SYSTEMIC ANKYLOSING SPONDYLITIS  Rheumatic disease  Start with inflammation of sacroiliac joint  Progress toward lumbotharacic  Begin with inflammation  causing ligaments calcification LUMBAR SPONDYLOIS  Degenerative changes  Primary With age or secondary with overweight, trauma, deformities.  Narrowing of intervertebral space..  Osteophytes FACET JOINT DYSFUNCTION  arthritis ( degeneration) / Block.  Limitation of the lumbar spine movement and pain during movement.  Facet joint pain can be referred to any part of the limb, but most commonly it is the gluteal and proximal thigh or groin region. DISC HERNIATION  Protrusion (A): breakdown  Prolapse (B): fissure/ tear  Extrusion (C):  sequestration (D):separation  in the absence of bowel/bladder dysfunction or progressive motor deficits, nonsurgical interventions should be exhausted before surgery including physical therapy  SPINAL CANAL STENOSIS  narrowing of the spinal canal nerve root canals, and intervertebral foramina.  Ligamentum flavum hypertrohpy can cause  Patients with spinal stenosis experience back pain, transient motor deficits, tingling, and intermittent pain in one or both legs; this is worsened by standing or walking (neurogenic claudication)  unlike claudication of vascular origin (which disappears quickly with rest), does not ease very readily with rest and may persist for several hours.  LUMBAR INSTABILITY  A lumbar segment is considered unstable when it exhibits abnormal movement in quality (abnormal coupling patterns) or in quantity (abnormal increased motion)  This instability can be asymptomatic or symptomatic, depending on the demands made on the motion segment.  Secondary Instability is seen in all ages—in the young, in spondylolisthesis or followin trauma; and in middle-aged or older patients, in degenerative conditions.  In the classic instability syndrome of spondylosis with a definable skeletal defect , hamstring tightness (in defense of the instability) is the classical sign. Transient neurologic signs, such as those arising from a spondylolisthesis and causing neurogenic claudication, indicate instability. SPONYLOLYSIS  Defect in pars interarticularis SPONDYLOLYTHESIS  Forward displacement of one vertebral over the other  Manly L5 on s1 or L4 on L5  Four grades  Retrolythesis is backward displacement RED FLAGS FOR LOW BACK REGION Back-related tumor  Age more than50 y  History of cancer  Unexplained weight loss, loss of appetite, night sweating.  Failure of conservative therapy back-related infection (spinal osteomyelitis)  Fever.  Recent infection (e.g., urinary tract or skin).  Intravenous drug user/abuser.  Concurrent immunosuppressive disorder. Cauda equina syndrome  Urine retention or incontinence  bowel incontinence  Saddle anesthesia  Global or progressive weakness in lower extremities  Sensory deficits in feet (i.e., L4, L5, S1 areas)  Ankle dorsiflexion, toe extension, and ankle plantarflexion weakness Spinal fracture  History of trauma (including minor falls or heavy lifts for individuals who have osteoporosis or are elderly)  Prolonged use of steroids  Age more than70 years  EVIDENCE (GUIDELINES)BASED TREATMENT FOR ACUTE LBP  11 countries guidelines (systematic review)  Regarding diagnosis, agreement exists that diagnostic triage is indicated to differentiate 1- nonspecific LBP 2- radicular syndrome 3- specific pathological conditions.  the history taking and physical examination must strive to identify red flags  screen the neurological system.  Radiographic examinations should not be used for the initial diagnosis of acute low back pain conditions in the absence of red flags,  and psychosocial factors should be assessed and considered as a component of a conservative approach. The guidelines also provide common recommendations for treatment for acute low back pain,  reassuring the patient of a favorable prognosis.  advising the patient to stay active.  prescribing medication if necessary, starting with paracetamol (acetaminophin), then considering non steroidal anti-inflammatory agents, and lastly considering muscle relaxants or opoids.  Discouragement of bed rest.  Consideration of spinal manipulation for pain relief were also recommended by most of the guidelines. For chronic low back pain  Exercise therapy  TREATMENT BASED CLASSIFICATION OF LBP Although clinicians often theorize the primary anatomic structure at fault, studies estimate that the true pathoanatomic structure causing low back pain can be identified in less than 15% of the cases the classification system has been modified based on results of clinical research studies to develop clinical prediction rules for manipulation and stabilization and based on results of reliability studies and randomized controlled clinical trials. The specific exercise category is based on a McKenzie approach for treatment of “derangements,” with use of repeated lumbar movements  The treatment-based classification system avoids the pitfalls of attempts to identify the pathoanatomic cause of the patient’s symptoms.  Lumbar spinal stenosis is perhaps the one main exception in which strong correlation between the pathoanatomic findings on imaging findings and a specific treatment approach seems to provide favorable treatment outcomes.  Studies showed significantly better outcomes from 4 weeks o classification-based physical therapy treatment compared with guideline-based treatment, which consisted of low-stress aerobic exercise and advice to remain active. FOUR CATEGORIES  Lumbar Hypomobility (Manipulation)  Lumbar Spine Instability (Stabilization)  Lumbar and Leg Pain That Centralizes (Specific Exercise)  Lumbar Radiculopathy That Does Not Centralize (Traction)  LUMBAR HYPOMOBILITY (MANIPULATION) Clinical prediction rules (4 from 5)  Hypomobility with passive accessory intervertebral motion testing  Low back and leg pain that does not travel beyond the knee  Low fear avoidance beliefs (FABQ work subscale 50 y)  Lateral shift Visible frontal plane deviation of the shoulders relative to the pelvis Symptoms centralize with side glide and backward bending  patients with a directional preference toward lumbar extension (repeated backward bending) may have a symptomatic intervertebral disc with an intact annulus  patients with a directional preference toward spinal flexion may have underlying spinal stenosis.  Once symptomatic improvement is achieved, these patients may benefit from general conditioning, mobility, and strengthening (stabilization) programs to restore function and prevent future episodes of low back pain.  Patients with leg pain that peripheralizes tend to have a poorer prognosis for conservative management; these patients may be candidates for activity modification, stabilization exercise, and spinal traction. LUMBAR SPINAL STENOSIS (FLEXION SYNDROME)  Neurogenic claudication has been defined as pain, paresthesias, and cramping of the lower extremities brought on by walking and relieved by sitting en alleviates the leg symptoms  The spinal canal is further narrowed in a lordotic posture and tends to widen in a more flexed posture  Spinal extension is commonly limited. Sitting or assuming a spinal flexion (forward bent) position often alleviates leg symptoms. The two-stage treadmill test:  the patient walking on a level treadmill for up to 10 minutes, followed by a 10-minute rest period in sitting  then another bout of walking on the treadmill set at a 15-degree incline for up to 10 minutes.  The speed is set at 1.0 miles per hour and then adjusted to a comfortable pace for the patient.  The patient is asked to report any symptoms increased beyond the baseline level and given the opportunity to stop the test before 10 minutes if symptoms become intense.  A positive test result for neurogenic claudication is demonstration of a greater tolerance for walking in the inclined position, which places the lumbar spine in a more flexed (forward bent) position.  LUMBAR RADICULOPATHY THAT DOES NOT CENTRALIZE (TRACTION)  No lumbar movements centralize symptoms  No directional preference noted with history or clinical examination to alleviate lower leg pain  Peripheralization of leg pain with lumbar backward bending  Positive SLR for lower leg pain at