SPINAL PAIN

1
SPINAL PAIN DYSFUNCTION

• THERAPEUTIC EXERCISE
• PTHA 2509

2
WAYS OF DETERMINING APPROPRIATE TREATMENT

• Treat pathology/diagnosis
• Treat with specific goal/symptoms

3
TREAT PATHOLOGY/DIAGNOSIS

• Treat causes of back pain
• muscle/ligament
• joint
• nerve root
• miscellaneous - fractures, stenosis
• Rarely clear-cut

4
TREAT PROBLEM/SYMPTOMS

• Pain, muscle spasming/guarding
• Loss of flexibility/general hypomobility
• General instability/hypermobility
• Poor posture
• Poor body mechanics
• Faulty living and working habits Poor ergonomic
  conditions
• General decline of physical fitness Poor
  physical condition
• Poor health habits
• Poor mental condition
• Abnormal function

5
CONTRAINDICATIONS TO TREATMENT BY PROBLEM

• Symptoms increase with rest or during the night
• Symptoms not associated with movement or body
  position.
• Symptoms cover large, nonspecific area not
  consistent with musculoskeletal pathology.
• Symptoms migrate from one joint to another.
• History of serious illness
• Patient does not respond to short trial of
  conservative treatment

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GOALS OF TREATMENT

• Restore function
• Patient education to prevent recurrence
• Pain relief
• Promote healing
• Restore anatomy
• Increase or decrease mobility
• Strengthen muscles
• Improve posture
• Teach body mechanics
• Improve fitness

7
PROBLEM 1PAIN, MUSCLE GUARDING, SPASM,
INFLAMMATION

• Normal muscle does not spasm
• Regardless of underlying cause, these symptoms
  must be treated for healing to occur
• Underlying cause may have resolved by the time
  these symptoms have been reduced

8
PAIN, MUSCLE GUARDING, SPASM, INFLAMMATION

• Findings
• Pain
• weight shift test
• Skin temperature changes
• Palpable spasms/tightness
• Treatment
• Rest with early mobility
• Modalities
• Soft tissue mobilization/stretching

9
PROBLEM 2SOFT TISSUE HYPOMOBILITY

• Talking about generalized stiffness
• Involves joint capsule, muscle, and/or fascia
  shortening
• Causes
• Can lead to

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SOFT TISSUE HYPOMOBILITY

• Findings
• Treatment

11
PROBLEM 3 - JOINT HYPERMOBILITY/INSTABILITY

• Too much general motion
• Due to
• Look for hypomobility nearby
• Can lead to

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JOINT HYPERMOBILITY/ INSTABILITY

• Findings
• Treatment

13
PROBLEM 4POSTURE

• Postural problems/deviations affect large numbers
  of patients and is often a contributing factor if
  not the main cause of their dysfunction.
• Three major factors that influence adult posture

14
PROBLEM 5POOR BODY MECHANICS

• Already covered in Basic Patient Skills course
• Integral to cover from the first day of therapy
  for every back/neck patient specific to their
  functional needs
• Important to cover not just in lifting but also
  bending, reaching, sitting, sleeping, and other
  work and recreational activities.
• Body mechanics, like posture, is mainly habitual
  and takes a lot of repetition to incorporate

15
PROBLEM 6POOR ERGONOMIC CONDITIONS

• Ergonomics are the worker behaviors and/or work
  station or job designs necessary to perform a
  task
• High risk of re-injury upon return to work if not
  addressed
• May require a job site evaluation by the P.T.

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PROBLEM 7POOR PHYSICAL CONDITION

• Sedentary lifestyle
• Often associated with
• Requires a lifestyle change
• Eventually the patient has to take responsibility
  for this on their own
• Use an individualized realistic approach
  emphasizing active involvement

17
PROBLEM 8POOR HEALTH HABITS

• Unhealthy living habits can contribute to back
  pain including
• Smoking
• Poor diet/nutrition
• Sedentary lifestyle
• Overweight

18
PROBLEM 9POOR MENTAL CONDITION

• Mental fitness can be a factor in back injuries
  including
• Stress
• Emotional problems
• Chemical dependency
• Lack of job satisfaction
• We can indirectly assist with these problems by
  treating the physical problems.

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PROBLEM 10ABNORMAL FUNCTION

• Overall goal is to restore function.
• May be with continued pain or disability.
• Patient education and functional exercise are the
  key.
• Work hardening and chronic pain programs

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BACK TO POSTURE

• Balance is the key
• Curves in the spine function
• Anything that alters one of the curves,
  predisposes the individual to problems
• Postural assessment in comparison to normal
  identifies dysfunction

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POSTURE3 POSTURAL PROBLEMS

• Lumbar flexion syndrome
• Lumbar extension syndrome
• Forward head syndrome

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LUMBAR FLEXION SYNDROME - FLATBACK

• Lumbar spine
• Pelvis
• Tight
• Pain
• Frequently seen in _______ problems

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LUMBAR FLEXION SYNDROME - TREATMENT

• Avoid
• Use
• Stretch
• Strengthen

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LUMBAR EXTENSION SYNDROME - HYPERLORDOSIS

• Lumbar spine
• Pelvis
• Pain
• Common during
• Tight
• Weak

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LUMBAR EXTENSION SYNDROME - TREATMENT

• Postural correction
• External support
• Stretch
• Strengthen

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FORWARD HEAD SYNDROME

• Center of gravity of head shifted anterior to the
  longitudinal axis
• Pain
• Upper cervical spine (suboccipitals)
• Lower cervical spine and upper thoracic spine

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FORWARD HEAD SYNDROME (cont.)

• Often accompanied by
• Muscle spasms
• May occur with

28
FORWARD HEAD SYNDROME - TREATMENT

• Treat lumbar problem
• Muscle spasms
• Postural correction
• Stretch
• Strengthen

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TREATMENT BY DIAGNOSIS
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SCOLIOSIS

• Abnormal curvature of the spine
• Rotation of the vertebral column around its axis
  occurs and may cause rib cage deformity
• 3-5 per 1000 kids will develop a scoliosis that
  will require some type of treatment
• Most common

31
ETIOLOGY

• Idiopathic
• Myopathic
• Neurologic

32
AGE OF ONSET

• Infantile
• Juvenile
• Adolescent

33
GENERAL CHARACTERISTICS

• _______ curve with __________ or compensatory
  curve that develops to balance the body
• Curves designated L or R based on _________ of
  curve by location
• May be two primary curves
• _________________ shoulders and pelvis

34
TWO TYPES OF SCOLIOSIS

• Functional
• Structural

35
FUNCTIONAL SCOLIOSIS

• May be caused by
• Can become structural if not corrected
• Curves straighten when places in _______ _______
  position

36
STRUCTURAL SCOLIOSIS

• _______curvature associated with vertebral
  _____________ and asymmetry of ligaments
• Can be caused by deformity of the vertebra,
  congenital malformation, musculoskeletal
  disorders (osteoporosis, RA, spinal TB) or
  neuromuscular disorders (CP, polio)
• ____________ curves regardless of position

37
DIAGNOSIS

• Forward bend test
• Postural assessment
• Check leg length or other asymmetries

38
MANAGEMENT

• Goals prevent severe and progressive
  deformities especially cardiopulmonary
  dysfunction
• Curve less than 20 degrees
• Curve 20-40 degrees
• Curve greater than 40-60 degrees

39
MANAGEMENT EXERCISE FOR MILD TO MODERATE
SCOLIOSIS

• Modalities prn to benefit exercises
• Traditional Exercise
• Intended to correct mild problem or prevent
  progression of curve
• Stretch
• Strengthen
• Questionable benefit and value of this type of
  exercise alone

40
MANAGEMENT NEWER AREAS OF EXERCISE

• Measured strength training with machines

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MANAGEMENT NEWER AREAS OF EXERCISE

• Schroth Method of exercises incorporating
  breathing and self-correction of curves
• Yoga for breathing and relaxation
• Pilates and other core stabilization exercisees

42
SPINAL ORTHOSES FOR MODERATE SCOLIOSIS

• Goal passive restraint to maintain curves
  within 5 degrees
• Successful in approximately 85 of cases
• Curves with apex between ____ and ____ respond
  best to bracing _____ or above have the poorest
  outcome
• Not done as commonly as previously

43
TYPES OF SPINAL ORTHOSES FOR SCOLIOSIS

• Milwaukee (CTLSO)
• Boston (TLSO)

44
TYPES OF SPINAL ORTHOSES FOR SCOLIOSIS

• Charleston Bending Brace

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SURGICAL CORRECTION

• Spinal fusion with ____________ rods
• Maximum protection phase

46
SURGICAL CORRECTION

• Moderate to Minimum Protection Phase
• No lifting for first _______ then add ____ pound
  per month up to ____ pounds for the first year
• Functional mobility is severely limited for first
  ______ months
• After ___ months non-contact sports okay
  (walking, riding stationary bike, swimming)
• By ____ ______can include other non-contact
  sports horseback riding

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NEW LESS INVASIVE SURGICAL PROCEDURES

• Anterior Thorascopy
• Not for all types
• Best for flexible R thoracic curve
• Not for those with a lot of kyphosis or from
  neuromuscular etiology
• Quicker rehab, shorter hospitalization

48
HERNIATED NUCLEUS PULPOSUS (HNP)

• A disorder in which there is displacement of the
  nuclear material beyond the normal confines of
  the annulus.

49
HNP GENERAL CONSIDERATIONS

• Not due to a single incident.
• Cumulative damage over a period of time.
• Factors that contribute to disc damage

50
DISC DYNAMICS

• Disc anatomy
• Nucleus
• Annulus
• Ring configuration
• Innervation
• Changes with aging

51
DISC DYNAMICS WITH MOVEMENTS

• Nuclear movement with flexion and extension (Fig.
  2-6)

• Disc dynamics with rotation (Fig. 2-7)

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NACHEMSONS STUDY ON INTRADISCAL PRESSURES (Fig.
2-8)
53
STAGES OF DISC HERNIATION (Fig. 5-8)

• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Stage 5

54
CLINICAL DIVISIONSOF HNP

• Mild to moderate
• Moderate to severe

55
LUMBAR SPINE - HNP

• Typical age
• Typical level
• C/o pain in low back, buttocks, posterior leg
  unilaterally
• Previous history of multiple episodes
• Lot of flexion activities

56
MILD TO MODERATE HNP LUMBAR SPINE CLINICAL
FINDINGS

• Posture
• Lateral shift

57
MILD TO MODERATE HNP LUMBAR SPINE CLINICAL
FINDINGS

• Pain
• Routine x-rays
• Prolonged sitting or forward bending

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MILD TO MODERATE HNP L-SPINE - TREATMENT

• Correct lateral shift

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MILD TO MODERATE HNP L-SPINE - TREATMENT

• Exercises

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MILD TO MODERATE HNP L-SPINE - TREATMENT

• Before McKenzie exercises, may need to
• Patient education
• After 6-12 weeks

61
MODERATE TO SEVERE HNP L-SPINE CLINICAL
FINDINGS

• Same symptoms as mild to moderate except

62
MODERATE TO SEVERE HNP L-SPINE CLINICAL
FINDINGS

• Attempts to correct lateral shift

63
MODERATE TO SEVERE HNP L-SPINE CLINICAL
FINDINGS

• May report decreased pain with flexion position

64
MODERATE TO SEVERE HNPL-SPINE - TREATMENT

• Traction first
• Exercises
• Then follow previous guidelines
• May need to use _____________

65
CERVICAL HNP

• Less common than lumbar HNP
• Generally involves ___________ disc

66
MILD TO MODERATE HNPC-SPINE CLINICAL FINDINGS

• Pain
• Clowards sign

67
MILD TO MODERATE HNPC-SPINE CLINICAL FINDINGS

• ROM
• Postural problems
• No neurological signs

68
MILD TO MODERATE HNPC-SPINE - TREATMENT

• McKenzie exercises for the cervical spine

69
MILD TO MODERATE HNPC-SPINE - TREATMENT

• Assess
• Patient education

70
MODERATE TO SEVERE HNPC-SPINE CLINICAL FINDINGS

• Same symptoms as mild to moderate except

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MODERATE TO SEVERE HNPC-SPINE - TREATMENT

• Traction
• Exercises
• Continue as previously described

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HNP EXTRUSION/ SEQUESTRATION

• All or part of the nuclear material has been
  extruded out through the annular rings into the
  spinal canal
• Signs and symptoms often unpredictable
• Usually more constant c/o pain not relieved by
  any position
• P.T. not very beneficial except for pain
  relieving modalities
• Often requires surgical intervention

73
CORE STABILITY

• Proximal stability for distal mobility is an
  accurate saying for many things including spinal
  dysfunction.
• Normally, deep core muscles contract to enable
  the extremity muscles to move effectively with
  less risk of injury
• Research has shown that patterns of muscle
  recruitment of these muscles is delayed and they
  fatigue more rapidly in patients with low back
  pain putting them at more risk for injury

74
CORE STABILIZING MUSCLES LUMBAR SPINE

• The main deep core stabilizing muscles of the
  lumbar spine are the

75
CORE STABILIZING MUSCLES CERVICAL SPINE

• The main deep core muscles of the cervical spine
  are the
• Longus Colli
• Multifidi

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STABILIZATION TRAINING

• First, learn the _____________ ____________ of
  muscle contraction and spinal position, usually
  the __________ position
• Then, learning to hold this position using the
  core muscles while simple ___________ motions are
  added
• These can be made more difficult by

77
SAMPLE STABILIZATION EXERCISES FLEXION-BIAS
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SAMPLE STABILIZATION EXERCISES EXTENSION-BIAS
79
WHO ARE STABILIZATION EXERCISES BEST FOR?

• These exercises could be utilized for virtually
  every patient that has spinal pain or
  dysfunction.
• However, they are the best choice for the
  following

80
OSTEOARTHRITIS

• Chronic and progressive disease with degeneration
  of the facet joints and/or intervertebral discs
  often with osteophyte formation
• Synonymous with
• Degenerative Joint Disease ( DJD)
• Degenerative Disc Disease (DDD)
• Spondylosis
• Lateral Spinal Stenosis

81
OSTEOARTHRITIS

• May be a normal process of aging but not all
  patients with OA will be symptomatic
• May also be found in younger patients
• More common in the _________ spine than _________
  spine
• When osteoarthritis exists, the patient is more
  vulnerable to increased aggravation and strain

82
SIGNS SYMPTOMS

• History -
• Tenderness at segmental level of involvement
• A and PROM limited or sometimes excessive
• Xray reveals degenerative process and narrowing
  of disc space
• If nerve root impinged, get true neurological
  signs

83
DISC OR JOINT CAPSULE CAUSING PAIN?

• Difficult if not impossible to determine but in
  general,
• If flexion increases pain
• If extension increases pain
• In more severe cases, both motions increase pain.

84
TREATMENTMILD TO MODERATE STAGE

• Modalities
• Gentle mobilization
• If hypomobile

85
TREATMENTMILD TO MODERATE STAGE

• More beneficial than straight flexion or
  extension might be
• If hypermobile
• Progress to

86
TREATMENTMODERATE TO SEVERE STAGE

• Modalities
• Mobilize
• If movement aggravates symptoms

87
FACET JOINT DYSFUNCTIONS

• Facet joints are synovial joint so are prone to
  the same dysfunctions that other synovial joints
  are
• Facet joint impingements
• Facet joint sprains

88
FACET JOINT IMPINGEMENTS

• Synovial lining and/or capsule becomes impinged
  between the joint surfaces
• Locked facet, blockage, subluxation, acute
  cervical torticollis
• Mechanism of injury

89
FACET JOINT IMPINGEMENTS

• Rest relieves pain
• Movements hurt with specific passive and active
  movements restricted/painful
• Patient c/o being locked and many times can
  specifically point to involved area
• No neurological signs but may have referred pain
• Routine xrays negative but a series of moving
  xrays may reveal hypomobile segment

90
FACET JOINT IMPINGEMENTS- TREATMENT

• Joint mobilization
• Modalities
• Traction perhaps
• Once mobility restored, look for underlying
  segmental hypermobility

91
FACET JOINT SPRAINS

• Very similar symptoms to facet impingement but
  treatment very different
• History of moderate to severe trauma
• Rest relieves movement hurts
• Movement more restricted generally and may
  involve more than one segment

92
FACET JOINT SPRAINS - TREATMENT

• Acute -
• Subacute -

93
OSTEOPOROSIS/COMPRESSION FRACTURES

• Causes of osteoporosis
• post-menopausal women
• genetic abnormalities
• nutritional dysfunctions
• endocrine disorders
• corticosteroids
• pregnancy
• prolonged immobilization
• inactivity/weightlessness
• Bone density screening xrays can pick up
  osteopenia or pre-fracture osteoporosis that can
  be medically treated with bone builders like
  Fosamax or Boniva

94
COMPRESSION FRACTURES

• Generally involve the
• Diagnosed by
• Pain
• Postural changes

95
COMPRESSION FRACTURES TREATMENT

• Medically
• Surgically

96
COMPRESSION FRACTURES -P.T. TREATMENT

• Patient Education
• Exercises
• Modalities
• Instruction regarding donning and doffing
  brace/corset
• Transitional movement training

97
SPONDYLOLYSIS/SPONDYLOLISTHESIS

• Spondylolysis - defect involving the pars
  interarticularis of the neural arch

98
SPONDYLOLYSIS/SPONDYLOLISTHESIS

• Spondylolisthesis - bilateral defect as above
  which allows anterior displacement of the
  vertebra and the one below it

99
SPONDYLOLYSIS/SPONDYLOLISTHESIS

• Diagnosed by xray or bone scan
• Palpable step-off of the spinous processes

100
SPONDYLOLYSIS/SPONDYLOLISTHESIS

• Postural changes
• Pain
• Increased risk of

101
SPONDYLOLYSIS/SPONDYLOLISTHESIS TREATMENT

• Avoid
• Exercises
• Lumbosacral orthosis

102
SPINAL STENOSIS

• Narrowing of the spinal canal
• Causes pressure on the spinal cord and gives
  neurological symptoms
• Causes

103
CERVICAL SPINAL STENOSIS

• Reflexes
• Other symptoms
• Symptoms aggravated by

104
LUMBAR SPINAL STENOSIS

• Neurogenic Intermittent Claudication of the Cauda
  Equina
• Pain
• Reflexes
• Other symptoms
• Symptoms increase with
• Symptoms relieved by
• Must rule out vascular insufficiency

105
SPINAL STENOSISTREATMENT

• Patient education
• Orthoses
• Modalities
• Exercises
• Severe cases require a decompression laminectomy

106
ANKYLOSING SPONDYLITIS

• Progressive joint sclerosis and ligamentous
  ossification (bamboo spine)

107
ANKYLOSING SPONDYLITIS

• Appears first in
• Spreads to
• Onset
• Gender
• Diagnosed by lab tests and later by xray

108
ANKYLOSING SPONDYLITIS

• c/o
• Symptoms
• Complete ____________ of involved joints
• Postural changes

109
ANKYLOSING SPONDYLITISTREATMENT

• Patient education/vocational counseling
• Positioning and exercise
• Lumbar roll when sitting
• Joint mobilizations
• Lumbar support and modalities prn during acute
  episodes

110
CERVICOGENIC HEADACHE

• Definition referred pain received in any part
  of the head caused by a primary nociceptive
  source in the musculoskeletal tissues innervated
  by the cervical nerves

111
CERVICOGENIC HEADACHE

• Source of the headache can be any structure
  innervated by

112
CERVICOGENIC HEADACHE - SYMPTOMS

• ________________ basis either _________ or
  ______________ times per week
• _______________ duration
• Unlikely to ___________ _____________
• Pain

113
CERVICOGENIC HEADACHE - SYMPTOMS

• May exist concurrently
• May be associated with _______ __________ or
  _________________
• May be relieved by

114
CERVICOGENIC HEADACHE - SYMPTOMS

• Extrinsic causative factors
• Intrinsic causative factors

115
CERVICOGENIC HEADACHE - TREATMENT

• Treat the musculoskeletal impairments

116
CERVICOGENIC HEADACHE - TREATMENT

• Address lifestyle or extrinsic risk factors
• Address intrinsic risk factors
• Address psychosocial risk factors