Spine Rehabilitation

Pam Lee, PT, MA, CSCS

Spine Rehabilitation Center

UIHC

November 11, 2004

Sports Medicine Conference

Larson Conference Room UIHC

Who is at more risk for low back injury?

Different Treatment Approaches

n     1.  Focus on the symptoms

n     2.  Focus on the source of symptoms and restrictive tissues - the tissue

n     3.  Focus on the cause of the symptoms and contributing factors.

n    Cause - the mechanical factor or movement impairment

                                                                                                                                                Sahrmann 2002

Movement - 3 factors

n     1.  Muscle performance

n    Proper strength and stability

n    Proper length

n     2.  Motor Control

n    Correct Timing

n    Proper recruitment of muscles

n    Corrections throughout movement

n     3.  Biomechanical factors

n    Balance, forces, alignment

Sahrmann - Movement Impairment Syndromes

n     Movement as a cause of pain syndromes.

n     Ideal alignment facilitates optimal movement

n     Spinal segments subjected to the most movement show degenerative changes.

n     Repeated movements and sustained postures alter tissue - micro trauma to macro trauma

Low back pain - Many things can go wrong.

n     Strain

n     Instability

n     Herniated disk and lumbar radicular pain

n     Spondylolysis and spondylolisthesis

n     Facet syndrome

n     Muscle imbalance

n     Poor posture, faulty alignment

n     Poor core stabilization -weak, motor control

Treatment of Spondylolysis

n     Avoid extension exercises and positioning

n     Strong core stabilization program

Treatment of herniated disk

n     Extension based exercise program

n     Decrease sitting, flexion,reduce lifting

n     Activity modifications

Treatment of Mechanical Low Back Pain

n      Alleviate the mechanical cause of the problem

n      Look at alignment and neuromuscular performance

Initial evaluation

n      Posture-above and below

n      Pain -Where? When? During which activities?

n      Mobility

n      Strength

n      Functional activities

n      Sleep

n      Bad habits

n      Sport position

What movement increases your pain?

n     Lumbar Movement Impairments

n    Flexion

n    Extension

n    Rotation

n    Rotation - Flexion

n    Rotation - Extension

  Clustering of potential findings          

                  Extension               Flexion

n      Characteristics                Older shorter              Younger taller

n      Abs                                Long/Weak                      Strong/stiff

n      Back extensors                Strong/Stiff                        Long/weak

n      Hip flexor length               Short/stiff                         Long

n      Hip extensor length          Long                                Short/stiff

n      Daily activities                  Sits extended                  Sits flexed

General Treatment Strategies

n      Identify direction susceptible to motion (direction that increases symptoms)

n      Shorten lengthened trunk and hip muscles, changes the length-tension relationship and improve control of abdominal muscles.

n      Lengthen shortened muscles

n      Train patient to move correctly to offset inherent faulty flexibility pattern

n      Teach patient to avoid daily habits and postures that contribute to symptoms.

Student postures

Foundation for spine rehab

n     Biomechanics of the spine

n     Spine stability system

n     Scientific rationale for core stabilization training

Biomechanics of Spine

A system of spinal stability

n     Elements of spinal stability

n    Passive Subsystem

n    Active Subsystem

n    Neural Control Subsystem

The Passive Subsystem

n     Bone, discs, ligaments, joints

n     Ligamentous function to limit motion, provided nocioceptive feedback and proprioception

The Active Subsystem

n      Consists of muscles and tendons

n      Amount of force generated depends on passive subsystem mechanoreceptors and how the neural subsystem interprets the information.

Neural Control Subsystem

n      Proprioceptive nerve endings in ligaments, tendons, muscles and CNS

n      NCS controls muscular subsystem via sensory feedback from both active and passive systems.

n      Quickly determines firing patterns- which muscles - how strong - then monitors and adjusts forces.

Dysfunction of passive subsystem

n     Over stretched ligaments

n     Annular tears

n     Endplate damage

n     Disc extrusion

n     Degenerative changes

Dysfunction of the active subsystem

n      Inhibited ability to receive or act on neural commands

n      Difficulty coordinating appropriate muscle tension

n      Decreased capacity for spinal system to stabilize

n      Suppressed feedback to neural control system

Dysfunction of the neural subsystem

n     Muscles firing inappropriately

n     Too small, large, early or late

n     Excessive muscular tension

n     Insufficient muscular recruitment may not support the spine

n     Repetitive activities may increase the likelihood of error in a poorly functioning neural subsystem.

Subsystem Adaptation

n     Passive Subsystem- increased stiffness of spine occurs with age - osteophyte  and facet hypertrophy

n     Active Subsystem-strengthening of selected muscle groups may help compensate for loss of passive stability.

n     Neural Subsystem- compensatory strategies-like to alter the timing of muscular contractions in anticipation of an external load

Scientific basis for core stabilization training

n     Hides et al. studied long term effects of core stabilization training for first -episode low back pain.

n     One group received specific exercise and control group no PT, just meds, rest.

n     Follow up questionnaires 1 and 3 years post injury show fewer recurrences of LBP in exercise group, even if not doing exercises any longer.  (1 year 35% to 84%) (3 year 35% to 75%).

Scientific basis for core stabilization training

n     O’Sullivan et al. (1997) studied effects of 10 weeks of specific stabilizing exercise for CLBP and radiologic diagnosis of spondylolysis and spondylolisthesis.

n     Control group received primary care treatment.

n     Findings that exercise group demonstrated significant decrease in pain and functional disability level compared to control at 30 months.

Transversus Abdominus studies

•      Hodges and Richardson (1996) found  a delay in transversus abdominis contraction in pts. with low back pain as compared to person without pain with rapid arm motions.

•      They concluded delay implies a motor control deficit and inefficient stabilization.

•      Cresswell et al. (1994) found anticipated loads produced preactivation of all abdominal muscles prior to perturbation (T Ab.fires first).  Unanticipated ventral loads produced activity in all abdominal muscles in advance of erector spinae muscles.

Multifidus studies

n     Hides et al. (1994) found lumbar multifidus atrophy correlated to the same side and vertebral level of symptomatic back pain.

n     Yoshihara et al (2003) found atrophy of multifidus muscle at involved level in pts with lumbar disk herniation when compared to other levels.

n     Hides et al (1996)  found multifidus muscle recovery is not automatic after resolution of acute first episode of low back pain

The Core - Lumbo-Pelvic-Hip

n     It is our COG

n     Most movements initiated from or translate through the core

n     Functional Kinetic Chain

Core Exercises

Functional Progressions

n    Slow to fast

n    Stable to unstable

n    Eyes open to eyes closed

n    Static to Dynamic

n    No perturbation to increasing perturbation

n    Sports specific - slowly introduce rotational, axial loading, repetitive motion

Phases of Core Stabilization

n    Phase 1:  Core Initiation

n    Phase 2:  Static Core Control

n    Phase 3:  Dynamic Core Control

n    Phase 4:  Reactive Core Control

Core Initiation - Phase 1

n    Teach neuromuscular control of the deep stability muscles -  neuromuscular re-education.

n    1 Pelvic Floor contraction 30-50%

n    2 Transverse Abdominis (drawing in)

n    3 Multifidus (swell back muscles)

Core Initiation

n     Seated, Prone

n     Standing

n     Quadriped

n     Supine, Half Kneeling, Tall Kneeling

n   Can use biofeedback pressure cuff

n   Tactile cues, short bouts frequently throughout the day

Static Core Control -Phase 2

n    Challenges the core control with movement of the extremities but no movement through the spine or core

Static Core Control

Dynamic Core Control -Phase 3

n     Challenges the core during dynamic motion of the core.

Dynamic Core Control

Reactive Core Control -Phase 4

n     Challenges the core in reaction to unexpected environmental influences.

Reactive Core Control

Each phase is not exclusive

n     Overlapping at end and beginning of phases

n     Progress to challenge athlete while maintaining proper form

n     Quality over quantity

Other tools in spine rehabilitation

n     Water, Total Gym, Swiss Ball, Sport Cord, Balance Sandals, Foam Roller, Bosu Ball, Body Blade

n     Aerobic conditioning - endorphins

n     Ice

n     Bracing

n     Focus least on modalities - ultrasound, e-stim, heat

n     Massage, TENS, traction

Aquatic therapy

Total Gym

Swiss Ball

Body Blade

Balance Sandals - Gluteal facilitation

n      Balance Sandals introduce instability while walking. Taking small steps, the effort required to maintain balance subconsciously activates the gluteal muscles and stabilizing muscles of the pelvis.

n      Bullock-Saxton et al. (1993) research shows two benefits

n     1.  Increase in gluteus maximus and

            medius activity

n     2.  Decrease in time to achieve

             75% maximum contraction

Foam Rollers

Bosu Ball              Sport Cord

Research and Core Stabilization

n     Recommended texts

n     Recommended journal articles relating to:

n    Core stability research

n    Multifidus studies

n    Transverse Abdominis studies

n    Spine Biomechanics

n    Gluteus Muscle Activation

n    Sudden perturbation or sudden load studies

More needs to be done…

Rotation                                  Flexion

Tall                                          Short

Thank you