Week # 5 MVC client – continued treatment Lumbar – Pelvis – Hip Complex Treatment approaches.

Week # 5

• MVC client – continued treatment

• Lumbar – Pelvis – Hip Complex

• Treatment approaches

Stability

Control system

Passive system

Active system

Panjabi 1992

PsychoSocial System

Case

• 33 yr old computer , data controller

• Complete assessment

• Treatment approach

Segmental Stabilizing System- muscles

• 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

• Subjective assessment• Inadequate information• Failure to discuss treatment options• Consent• Insufficient biomechanical examination• Physical limitation• Lack of confidence• Equipment

• Incompetence

Patient factors• 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– 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

• 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 Tractionsustained 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 1990Form 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

• Inner Unit • Transversus abdominus• Multifidus• Pelvic floor• diaphragm

• 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

Pubococcygeus

Ischiococcygeus

Iliococcygeus

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

• 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

• Osseous Integrity• Articular / Ligamentous

integrity• Myofascial integrity• Neural integrity

Extrinsic Factors

• Gravity

Right Hip Flexion

• 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

Feel from 0° to R1

AP through innominate

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

• 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 LearningExercise Progression • Commence co-activation of TA/multifidus

• Combine with pelvic floor contraction

• Increase holding time

• Increase number of contractions

• 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