Transcript Document

Week # 5
• MVC client – continued treatment
• Lumbar – Pelvis – Hip Complex
• Treatment approaches
PsychoSocial
System
Stability
Control
system
Passive
system
Active
system
Panjabi 1992
Case
• 33 yr old computer , data controller
• Complete assessment
• Treatment approach
Segmental Stabilizing Systemmuscles
• Palpation of multifidus
• Potential to activate Transversus Abdominis
– More cues of pelvic floor to decrease use of IO
Muscles
of the
Core
Spine 29( 1): 3-8, 2004
Trunk Muscle Strength,
Cross-sectional Area and
density in Patients with LBP
Randomized to Lumbar
Fusion or Cognitive
Intervention Exercises
Keller et al
Exercise patient - cross
sectional increase by 12% and
density 16%
No exercise patient – fusion
No change cross- sectional
and density decreased
Core Kinnections
Heather Curilla PT Susan Massitti FCAMT
Multifidus contracting = stability
Multifidus Activation
Lab
• Assess ability of the Transversus abdominus
to contract
• Assess function of multifidus using
palpation and motor firing
Treatment Approaches
• Mobilizations , Manipulations
- cautions to mobs end range and manips
• Exercise
• Education
Therapist factors
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Subjective assessment
Inadequate information
Failure to discuss treatment options
Consent
Insufficient biomechanical examination
Physical limitation
Lack of confidence
Equipment
• Incompetence
Patient factors
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Lack of consent
Mental status
Obsession with manipulation
Inability to communicate
Unable to relax
Pain
Intoxicated/heavily medicate
Inappropriate end feel
Instability
Bony elements
• Fractures – presently
healing
• Dislocations presently healing
Bony elements
• Active infection – osteomyelitis,
tuberculosis
• Congenital anomalies
• Gross foraminal or spinal canal
encroachment on x-ray
Neurological
• Extra segmental pain increase with passive neck
flexion
• Bilateral or quadrilateral multisegmental
paraesthesia
• Hyperreflexia
• +babinski, oppenheimer, hoffman
• Clonus
• Ataxia
• Neurological spasticity
Neurological
• Bladder and bowel dysfunction
• Nystagmus
• Dysphagia/dyshasia
• Wallenberg’s syndrome ( PICA)
• Other cranial nerve S/S
Spinal cord disease/injury
• Extrasegmental pain BELOW level of
lesion  with PNF
• Bilateral , quadrilateral parasthesia,
weakness, spasm hyperreflexia hyporeflexia
below level of lesion
• Ataxia
Vascular considerations
• Vertebral artery
• Vascular disease
• Bleeding disorders
• Aortic graft
Soft tissue
• Collagen diseases
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Ehler’s –Danlos Syndrome
Marfan’s Syndrome
Osteogenasis imperfecta
Achondroplasia
Benign Hypermobility ( Caution)
Age
• Elderly – tissue health
• Children – consent , skeletal maturity
Metabolic Disease
• Bone Disease
• Osteoporosis
• Paget”s
Systemic Disease /Condition
• Diabetes ( caution)
• Endocrine disorders ( caution)
• Haemophilia
• Pregnancy
Inflammatory Diseases
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Active inflammatory disease
Rheumatoid Arthritis
Ankylosing Spondylitis
Psoariatic Arthritis
Reiter’s Inactive inflammatory Disease
( caution)
Medication
• Anticoagulants
• Any med that effects collagen
eg corticosteriods, tamoxifen
• Med linked to osteoporosis
• Anti-depressants ( caution)
References
• Greenspan, A., Orthopedic Radiology, Lippincott Williams
& Wilkins, philadelphia, 2000, 3rd edition
• Daffner, R., Clinical Radiology, 2nd edition, Lippincott
Williams & Wilkins, 1999
• Grieve, G., Modern manual therapy, 2nd edition, Churchill
and Livingstone, 1994
• Goodman & Boissonnault, Pathology; Implications for the
physical therapist, W.B. Saunders company, 1998
• Level 2 upper manual, 2002
• A special thanks to Lenerdene Levesque and Scott
Whitmore for the use of pathology slides
Treatment Options
• Mobilization, manipulation
• Exercise Rehab
• Muscle Retraining
• Education
Lumbar Traction
sustained vs oscillations
Unilateral Flexion
Lab
• Demo of Flexion gap manipulation
• Demo and practice sustained traction,
graded flexion with muscle activation
Pelvis
• When to look further
• Some assessment tools
Kinetics of the Lumbo-Pelvic
Region
• The lumbo-pelvic region is required to
transmit the weight of the head and the
trunk to the lower extremities
• Also functions to resist the forces incurred
by the lower and upper extremities.
Transmission of Force
Vleeming et al 1990
Form closure
Form closure refers to a
stable situation with
closely fitting joint
surfaces, where no
extra forces are needed
to maintain stability of
the system.
Clinical Relevance
• Compare left to right of same patient not
normal to abnormal
• Neutral zone motion requires the analysis of
a small range of movement near the joint’s
neutral position where minimal resistance is
given by the capsule and ligaments
Neutral Zone Theory
• Panjabi describe a small
range of displacement near
a joints neutral position.
• He has found that the
range of the neutral zone
may increase with trauma,
degeneration and weakness
of the stabilizing structures
What can affect the neutral zone?
Force Closure
Force closure refers to
the extra forces required
to keep an object in place.
The amount of force
closure required is
dependant on the
coefficient of friction of
the articular surfaces
Force Closure – Ligaments
• Several strong ligaments connect the
innominate and sacrum
• Ligament tension varies with
sacral/innominate position
Long Dorsal Lig
Self- locking ( CPP) of the SIJ
• Nutation of the sacrum tightens the major
SIJ ligaments
• The sacrum nutates whenever the body is
vertical and increases in sagittal plane
motion
Sacral Nutation
Nutation resisted by interosseus and sacrotuberous
ligaments
Vleeming and Lee 1997
Unlocking ( LPP) of the SIJ
• Counternutation increases tension in the
long dorsal ligament
• Occurs in supine lying
Counternutation of the
sacrum tightens the long
dorsal ligament
Vleeming and Lee 1996
Force Closure – muscles
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Inner Unit
Transversus abdominus
Multifidus
Pelvic floor
diaphragm
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Outer Unit
Anterior oblique
Posterior oblique
Deep longitudinal
lateral
Inner Unit
• Pelvic floor and
Multifidus work as a
force couple to
stabilize the sacrum
• This enhances the
ability of the TA to
stabilize the spine
Inner unit – pelvic floor
Levator ani
Puborectalis
Pubococcygeus
Iliococcygeus
ischiococcygeus
Ischiococcygeus
Iliococcygeus
Pubococcygeus
Pelvic Floor - Function
Collective action all 4 parts
pulls your tailbone and
sacrum forward
Isolated contraction
ischiococcygeus
compresses the SIJ
Isolated contraction
pubococcygeus
compresses the PS
Inner unit- Force couples and
Force closures
• Sacral position controlled by multifidus, ilio
and ischiococcygeus
• Pubic symphysis stabilized by
pubococcygeus , TA, IO
Anterior Oblique System
• Internal and External
oblique
• Contralateral
Adductors
• Intervening anterior
abdominal fascia
Posterior Oblique System
• Ipsilateral Gluteus
Maximus
• Contralateral
Latissimus dorsi
• Thoracodorsal fascia
Longitudinal Sling
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Tibialis anterior
Peroneus longus
Biceps femoris
Sacrotuberous ligament
• Vleeming and Lee 1997
Lateral System
• Gluteus Medius
• Gluteus Minimus
• Contralateral
Adductors
Stability of the System
As a consequence of Form and Force
closure the stability of a system (the ability
to effectively transfer loads through joints)
is dynamic and depends on many factors
acting at the moment.
Stability of the System
Intrinsic Factors
Extrinsic Factors
• Osseous Integrity
• Articular / Ligamentous
integrity
• Myofascial integrity
• Neural integrity
• Gravity
Right Hip Flexion
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Right innominate rotates posteriorly
Left rotates Anteriorly
Sacrum rotates to the right
Right PSIS should drop down relative to the
sacrum
Clinical Relevance
• Test helps identify ability to transfer load
through two legs
• Ability to balance on one leg
Active SLR
Mens et al 1997
• Developed to look at load transfer through the
pelvis in NWB position
• Can apply form closure in various locations
( ASIS , PSIS , trochanters)
• Can assess force closure mechanisms
Active SLR
• Patient Supine
• Palpate the ASIS of the side being
tested
• Have the patient raise the leg
through a SLR
• Note movement of the pelvis and
trunk
• Add form closure
• Add resistance through the
Anterior oblique system
Abdominal bulging
Specific Analysis of the Neutral Zone for the
SIJ
• Examines the ability of the SIJ to resist
vertical and horizontal translation forces
( shear) that are applied passively in NWB
( Lee 1992,1997, 1999)
Specific Analysis of the Neutral Zone for the
SIJ
• Need to find the plane of the joint
Specific Analysis of the Neutral Zone for the
SIJ
AP through innominate
Feel from 0° to R1
Specific Analysis of the Neutral Zone for the
SIJ
• Does not assess how much movement but
the stiffness value of the system
• Compare right to left for that patient
• Test when the force closure mechanism is
effective
Motor Control is NOT a
birthright
Richardson et al 1999
Exercise Design
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Initially isometric
Co-contraction of deep abds and multifidus
Low level tonic contraction
Low load to start
High repetitions
Progress to dynamic functional movements
of the trunk
The Core and
the Lower
Extremity
Motor Learning
• Formal motor skill training
• Perception of the specific contraction
• Understand the task, what it feels like, instructions, visual
cues, different postures/positions, various facilitation and
feedback
• Enhance the patients perception of the deep muscle motor
skill
• Focus on one particular muscle at a time
Motor Learning
Associative Stage  Automatic Stage
• “Got the idea”  practice  thousands of repetitions
• Care with fatigue
Motor Learning
Exercise Progression
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Commence co-activation of TA/multifidus
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Combine with pelvic floor contraction
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Increase holding time
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Increase number of contractions
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Reduce feedback
• Add diaphragmatic breathing (abdominal wall movement
while maintaining a deep muscle contraction) Intermediate
steps to encourage air flow: counting, talking
Rehabilitation Process
• Facilitation / Isolation of inner unit
• Re-educate the control of the inner unit
• Maintain control of inner unit while training outer unit
• Functional retraining
Lab
• Exercise program for weak TA/ multifidus
in sitting, standing, lifting
References
• Therapeutic Exercise for Spinal Segmental Stabilization in
Low Back Pain Scientific Basis and Clinical Approach
Richardson, Jull, Hodges, Hides 1999
• The Pelvis Girdle An Approach to the examination and
treatment of the lumbo-pelvic –hip region Lee 2004
• Post Partum Health for Mothers CD Diane Lee 2001