Week # 5

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

2. PsychoSocial System

3. Case • 33 yr old computer , data controller • Complete assessment • Treatment approach

4. Segmental Stabilizing System- muscles • Palpation of multifidus • Potential to activate Transversus Abdominis • More cues of pelvic floor to decrease use of IO

5. Muscles of the Core

6. 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%

7. No exercise patient – fusion No change cross- sectional and density decreased

8. Core Kinnections Heather Curilla PT Susan Massitti FCAMT

10. Multifidus contracting = stability

11. Multifidus Activation

12. Lab • Assess ability of the Transversus abdominus to contract • Assess function of multifidus using palpation and motor firing

13. Treatment Approaches • Mobilizations , Manipulations - cautions to mobs end range and manips • Exercise • Education

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

15. Patient factors • Lack of consent • Mental status • Obsession with manipulation • Inability to communicate • Unable to relax • Pain • Intoxicated/heavily medicate • Inappropriate end feel • Instability

16. Bony elements • Fractures – presently healing • Dislocations - presently healing

17. Bony elements • Active infection – osteomyelitis, tuberculosis • Congenital anomalies • Gross foraminal or spinal canal encroachment on x-ray

18. Neurological • Extra segmental pain increase with passive neck flexion • Bilateral or quadrilateral multisegmental paraesthesia • Hyperreflexia • +babinski, oppenheimer, hoffman • Clonus • Ataxia • Neurological spasticity

19. Neurological • Bladder and bowel dysfunction • Nystagmus • Dysphagia/dyshasia • Wallenberg’s syndrome ( PICA) • Other cranial nerve S/S

20. Spinal cord disease/injury • Extrasegmental pain BELOW level of lesion  with PNF • Bilateral , quadrilateral parasthesia, weakness, spasm hyperreflexia hyporeflexia below level of lesion • Ataxia

21. Vascular considerations • Vertebral artery • Vascular disease • Bleeding disorders • Aortic graft

22. Soft tissue • Collagen diseases • Ehler’s –Danlos Syndrome • Marfan’s Syndrome • Osteogenasis imperfecta • Achondroplasia • Benign Hypermobility ( Caution)

23. Age • Elderly – tissue health • Children – consent , skeletal maturity

24. Metabolic Disease • Bone Disease • Osteoporosis • Paget”s

25. Systemic Disease /Condition • Diabetes ( caution) • Endocrine disorders ( caution) • Haemophilia • Pregnancy

26. Inflammatory Diseases • Active inflammatory disease • Rheumatoid Arthritis • Ankylosing Spondylitis • Psoariatic Arthritis • Reiter’s Inactive inflammatory Disease ( caution)

27. Medication • Anticoagulants • Any med that effects collagen eg corticosteriods, tamoxifen • Med linked to osteoporosis • Anti-depressants ( caution)

28. 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

29. Treatment Options • Mobilization, manipulation • Exercise Rehab • Muscle Retraining • Education

30. Lumbar Tractionsustained vs oscillations

31. Unilateral Flexion

32. Lab • Demo of Flexion gap manipulation • Demo and practice sustained traction, graded flexion with muscle activation

35. Pelvis • When to look further • Some assessment tools

36. 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.

37. Transmission of Force

38. 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.

40. 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

41. 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

42. What can affect the neutral zone?

43. 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

44. Force Closure – Ligaments • Several strong ligaments connect the innominate and sacrum • Ligament tension varies with sacral/innominate position

46. Long Dorsal Lig

47. 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

48. Sacral Nutation Nutation resisted by interosseus and sacrotuberous ligaments Vleeming and Lee 1997

49. 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

50. Inner Unit Transversus abdominus Multifidus Pelvic floor diaphragm Outer Unit Anterior oblique Posterior oblique Deep longitudinal lateral Force Closure – muscles