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Lumbar Spine Core Shelley Payne, MS, PT, ATC ATHT 340 Structure and Function Primary and Secondary Curves Structure and Function Body of vertebrae is not solid bone, but cortical bone Better able to absorb forces and minimize weight of total vertebra Neural Arch Pars Interarticularis (lamina) Movement Assessment Lumbar flexion, extension, rotation, and side-bending ROM Can measure distance from floor OR use an inclinometer Lumbo-pelvic Rhythm? Looking for “aberrant motion” (instability catch, painful arc, “thigh climbing”, reversal of lumbopelvic rhythm) ?Lumbopelvic Rhythm? Lumbar Flexion/Extension Flexors act to balance pull of back extensors in standing… they are NOT “active” Multifidus deep to erector spinae Back extensors NECESSARY to maintain stability in standing Lumbar Flexion/Extension Flexion of trunk against gravity requires anterior abdominal muscles (ie, a sit-up) Forward flexion is mostly produced by gravity Agonists? Antagonists? What mode? Implications for Lifting Extensors at maximum length with fwd flexion (lengthtension relationship) Fwd flexion significantly increases intradiskal pressure in lumbar area Implications for Lifting Don’t TWIST! Annulus fibrosis resists torsion, but risk of disc rupture increases if you bend and rotate at the same time Flexibility Assessment SLR… will discuss later Hip IR/ER Ober’s Thomas Test Glut and Hip rotator tightness clinically significant! WHY? What is the implication for the lumbar spine? What is “The Core” Defined as the lumbarpelvic-hip complex Location of our Center of Gravity “Stabilizing Corset” Forms hoop around abdomen Active portion fired via transverse abdominus What is “The Core” Erector Spinae Quadratus Lumborum Latissimus Dorsi Multifidus Abdominals Abdominals Rectus Abdominus: eccentric deceleration of trunk extension & lateral flexion External Obliques: concentric opposite rotation and same lateral flexion; eccentric trunk extension, rotation and lateral flexion Abdominals Internal Obliques: Synergist to Transverse Abdominus Transverse Abdominus: stabilization against rotation IO & TA contract in a feed-forward mechanism prior to limb movement!!! What Can The “Core” Do For You? Force Reduction (Eccentric Contractions) Dynamic Stabilization Relationship to the kinetic chain The SCARY Low Back Let the evaluation DRIVE your treatment plan!!! Know your patient population Use the subjective evaluation and patient population to narrow the focus of your evaluation Clinical Prediction Rules “A pathology-based approach to diagnosis for LBP has proven difficult because of the inability to identify a structural pathology in the vast majority of patients with LBP.” Classifying patients into subgroups (age, symptom duration, distribution) could guide diagnosis and treatment of LBP (Hicks GE et al. Arch Phys Med Rehabil. 2006: 86;1753-1762.) Lumbar Stabilization Programs Exercises designed to improve spinal stabilization have gained popularity in the conservative treatment of patients with LBP How do we know which patients will respond to this model of treatment? Lumbar Segmental Instability Unique subgroup of patients with LBP Condition in which there is a loss of stiffness between spinal motion segments “If LSI could be accurately diagnosed, the conservative treatment of choice would be a lumbar stabilization program…” (Hicks) Special Tests Prone Instability Tests -if pain is present on passive provocation testing of the vertebral levels but disappears when spinal extensors are active, then the muscle activity may be able to stabilize the segment and reduce the pain Lumbar segmental mobility testing…limited mobility in one area often leads to hypermobiility in another Core Stability Assessment Side Support Test Extensor Endurance Active sit-up (Sahrmann MMT grades) Active bilateral SLR test OR bilateral leg lowering test Strength Assessment DO NOT forget the hip abductors and their contribution to core stability…base of support for core structures Hip extensors also important in their contributions to extensor strength…stabilizers of the trunk over a planted leg One leg standing balance ability (Trendelenburg) One leg squat Three-plane core strength test (Kibler)… no reliability or validity has been done Sacroiliac Joint Permit small amount of motion that varies among individuals SI joint and the pubic symphysis are linked in the CKC… movement in one causes movement in the other Muscle attachments near the pubic symphysis? Muscle attachments to the sacrum? SI joint anatomy SI joint anatomy Clinical Prediction Rule SI Joint Dysfunction Clinically this subgroup with LBP responds favorably to manipulation Muscle energy techniques and/or mobilization are appropriate May help explain cases that are not improving Assessment of SI Joint Provocation, Motion and Pelvic Symmetry Tests (Flynn et al. Spine. 2002:27(24); 2835-2843) Provocation tests more reliable (Gaenslen, Sacral Sulcus) Clinically, malleolar height, ASIS and PSIS height are helpful Clinical Prediction Rule Spinal Manipulation More recent onset of symptoms (<16 days) One hip with >350 internal rotation ROM Hypomobility of the lumbar spine (lumbar segmental testing) No symptoms distal to the knee Other Special Tests Significant SLR Decreased SLR ROM is related to presence of radiculopathy and generally a worse prognosis How is this different than hamstring tightness? Measuring Success Modified Oswestry Low Back Disability Index http://moon.ouhsc.edu/dthompso/CDM/osmod.doc RED FLAGS Loss of bowel or bladder function Symptoms unrelated to position or movement, especially night pain and/or night sweats Unexplained weight loss of more than 5 kg History of direct blunt trauma Abdominal pain with radiation into groin Body temp > 1000 F Resting HR > 100 bpm Resting respiration greater than 25 breaths/min References Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain. Spine. 2006;31(6):623-631. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753-1762. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27(24):2835-2843. Kibler WB, Press J. Sciascia. The role of core stability in athletic function. Sports Med. 2006;36(3):189-198. Manal TJ, Claytor R. The Delitto Classification scheme and the management of lumbar-spine dysfunction. Athletic Therapy Today. 2005:9;17-25.