chapter 18

1. chapter18 Spine and Sacroiliac

2. Vertebral Column 33 vertebrae • 7 C/S (cervical spine) • 12 T/S (thoracic spine) • 5 L/S (lumbar spine) • 5 sacral • 4 coccygeal

3. Spinal Curves • Primary curve • Kyphosis: “C” curve • Convex posteriorly • Thoracic and sacral regions • Secondary curve • Lordosis • Convex anteriorly • Cervical and lumbar regions

4. Curve Functions Dynamically • Extension:  lordosis /  kyphosis • Flexion:  lordosis /  kyphosis

5. Good News-Bad News of Spine Curves • Good News: • Provide strength and resilience to column • Compressive forces are shared between convex curves and supporting soft tissue • Absorb, distribute, and dissipate loads through axis • Bad News: • Consequence = Shear forces at transition zones  potential breakdown sites

6. Curvature Line of gravity in anatomical position Mastoid process Anterior to L/S junction and sacroiliac (SI) joint Anterior to 2nd sacral vertebra Posterior to hip joint Anterior to knee joint Anterior to ankle (continued)

7. Curvature (continued) Structures contributing to curves: • Intervertebral discs: broader anteriorly in cervical and lumbar regions • Orientation of articular processes/facets • Attachment/alignment of ligaments and muscles

8. Curvature Variability • Changes in one curve  compensation in joints above and below • Exaggerated curves   stress to muscles, ligaments, joints, discs, sometimes nerves • Exaggerated curves change volume within body cavities

9. Treatment Program Considerations • Examination • Healing process • SINS • Response to previous treatment • Modalities: pain, edema, healing • Need to maintain level of conditioning • Goals and progression

10. Williams’ Flexion Exercises • Paul C. Williams, orthopedic surgeon • Lordosis the cause of back pain • Six exercises for chronic low-back pain (LBP) • Emphasis on flexion • Strengthening of abdominal and gluteal muscles • Stretching of hip flexors and erector spinae

11. Figure 18.1a

12. Figure 18.1b

13. Figure 18.1c

14. Figure 18.1d

15. Figure 18.1e

16. Figure 18.1f

17. Figure 18.1g

18. McKenzie Extension Program Robin McKenzie: New Zealand physiotherapist Disc the primary cause of back pain Predisposing factors in back pain: Prolonged sitting in flexion Frequency of flexion Lack of extension Emphasis on extension to relieve disc pressure

19. McKenzie Mechanical Syndrome Classifications • Postural syndromes • Dysfunctions • Derangements

20. Postural Syndromes • Pain in LB (L/S), in neck (C/T), or interscapular (T/L) • No N/T • Intermittent • Non-severe • Age: teens, early 20s • Aggravating factor: prolonged postures • History: gradual onset, insidious; often comes on with change in activity, lifestyle • Exam: essentially negative • Can progress to dysfunction

21. Dysfunctions • Loss of accessory movement, adaptive shortening  pain • Pain: constant or intermittent, changes with postural stresses • Aggravating factor: prolonged posture • Easing factor: movement • Exam:  range of motion (ROM), rep ROM  pain, Ø neural signs and symptoms (S/S), Ø tension S/S, palpation = stiffness,  sacrotuberous (ST) mobility • Rx: posture, correct deficiencies, moderate

22. Derangements • Movements of the spine influence disc hydrostatic mechanisms. • Normal position of vertebrae is altered, causing alteration in disc nucleus. • Disc is source of pain, not inflammation. • If derangement is medial to nerve root, shift is to the side of pain. • If derangement is lateral to nerve root, shift is away from pain.

23. McKenzie Derangements: #1 • Mild disc bulge • Central/symmetrical pain • Rarely referred pain • Pain = secondary to irritation of posterior annulus and posterior longitudinal • Ligament (PLL) • Pain subsides in a few days • Rx: education for posture and mechanics, exercises

24. \QQ AU: XQQ\ McKenzie Derangements: #2 • Moderate disc bulge • Central/symmetrical pain • May or may not have buttock/thigh pain • Flat lumbar spine • Difficulty with position changes or sustained sitting • Rx: position prone; add treatment for #1

25. McKenzie Derangements: #3 • More posterolateral bulge • Unilateral/asymmetrical pain • Buttock/thigh pain • No deformity • Goal: centralize pain • Rx: Repeated extension in lying (REIL); add treatment for #1

26. McKenzie Derangements: #4 • Unilateral or asymmetrical pain • Buttock/thigh pain • Lateral shift (lumbar scoliosis) • Rx: correct shift; centralize pain; treatment as for #1

27. Figure 18.2a

28. Figure 18.2b

29. McKenzie Derangements: #5 • Unilateral/asymmetrical pain • Buttock/thigh pain with pain below knee • No deformity • Bulge causing annular, nerve root, dural irritation • Rx: REIL; cautious progression to centralization to elimination; treatment as for #1

30. McKenzie Derangements: #6 • Unilateral/asymmetrical pain • Buttock/thigh pain with pain below knee • Complaints of paresthesia, weakness, numbness • Lateral shift • Disc herniation • Rx: carefully reduce shift; centralize pain; treatment as for Derangements 1-4; avoid flexion 8-12 weeks

31. McKenzie Derangements: #7 Unilateral/asymmetrical pain Buttock/thigh pain Fixed lumbar lordosis Anterior or anterolateral bulge irritation to annulus, anterior longitudinal ligament (ALL) Rx: Repeated flexion in lying (RFIL), repeated flexion in standing (RFIS) with progressive knee flexion

32. Figure 18.3a

33. Figure 18.3b

34. Figure 18.3c

35. Figure 18.3d

36. Figure 18.3e

37. Figure 18.3f

38. Figure 18.3g

39. Figure 18.3h

40. Elements of Complete Spine Program • Modalities • Joint and soft-tissue mobilization • Posture correction and stabilization • Exercises • Cardiovascular • Flexibility • Strength and endurance: • Abdominal muscles: stabilizers and movers • Spinal: stabilizers and movers • Hips

41. Soft-Tissue Referral Patterns • Cervical can refer to shoulder • Thoracic can refer to cervical or lumbar • Lumbar can receive referrals from T/S and SI

42. Figure 18.4a

43. Figure 18.4b

44. Figure 18.4c

45. Figure 18.5a

46. Figure 18.5b

47. Figure 18.5c

48. Figure 18.6a

49. Figure 18.6b

50. Figure 18.6c