Back Me Up!

Dr Judi Laprade

Associate Professor, Division of Anatomy,

University of Toronto

Lead Trainer, Bone Fit

Outline of Presentation

Overview of vertebral anatomy

Overview of spinal musculature

Biomechanics of spinal fractures

Using anatomy & biomechanics to

guide rehabilitation

Sample exercises

Q & A

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6

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Thoracic Vertebral Anatomy

(c) Superior view

ANTERIOR

Spinous process

Lamina

Vertebral foramen

Transverse process

Pedicle

Vertebral body

1

Principles of Human Anatomy, Torotora 14e

POSTERIOR

Thoracic Vertebral Anatomy

(d) Right lateral view

ANTERIOR POSTERIOR

Transverse process

Superior

articular facet

Inferior articular facet Spinous process

Vertebral body Pedicle

1

Principles of Human Anatomy, Torotora 14e

Role of the

Vertebral Components 1

Essential’s of Clinical Anatomy; Moore,13e

Segmental Movement

oMovements freest in C region: facets

large and almost horizontal

oT region: stability due to connection of

ribs and costal cartilages to sternum;

Rotation good; Flexion and lateral

flexion limited (2-3 degrees/segment).

oL region: flexion/extension good:

sagittally oriented facets; lateral flexion

good; interlocking of facets limits

rotation (2-3 degrees/segment).

1

Essential’s of Clinical Anatomy; Moore,13e

Ligaments of Spine

___ Resists Flexion

___ Resists Extension

1

Essential’s of Clinical Anatomy; Moore,13e

Superficial Spinal Musculature:

? ‘Postural’ Muscles

TRAPEZIUS

LATISSIMUS

DORSI

RHOMBOID MINOR

RHOMBOID MAJOR

SERRATUS

ANTERIOR

o Muscles either originate or

insert to the spine

o Prime movers of the

scapula and humerus…

NOT direct movers of the

spine

2

Principles of Human Anatomy, Torotora 14e

Intermediate

Spinal Muscles

(b) Posterior view

ILIOCOSTALIS

SPINALIS

LONGISSIMUS

o Muscles originate off of

spinal segments & ilium

o Insert onto ribs, spinous or

transverse processes

o Prime movers of the spine

o ERECTOR SPINAE group

2

Principles of Human Anatomy, Torotora 14e

Deep Spinal

Muscles

o Muscles ALL originate on the

transverse processes

o Insert onto the spinous processes

above (1-6 segments)

o Act to either rotate (unilateral) or

extend (bilateral) spine

o TRANSVERSOSPINALIS group

2

Muscles in

Cross-section

Superficial

Intermediate

Deep

2

Essential’s of Clinical

Anatomy; Moore,13e

Physiological Fact:

Sarcopenia & OP Co-exist

Ciolac, 2013

http://www.scielo.br/scielo.php?pid=S1807-59322013000500710&script=sci_arttext

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Osteoporotic Fractures

ABNORMAL FORCE NORMAL FORCE

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Habitual slouching posture, repetitive lifting, or ADLs which encourage flexion of spine

Move the line of gravity anterior to vertebral

body increasing flexion moment

Resulting

MICROFRACTURES of

anterior vertebral bodies

Increases spinal extensor muscle activity to

counter the flexion moment

10-fold increase in

compressive forces on

anterior portion of

vertebral bodies in

thoracic region compared

to erect posture

Extensor muscle contraction further

increases vertebral compression loads &

accounts for 92-100% of stress on spine

PRESENCE of suboptimal bone density

ANTERIOR WEDGING & FRACTURE

DEVELOPMENT OF POSTURAL HyperKYPHOSIS

(Briggs, 2004; Sinaki, 2007; Duan, 2001)

3

Anatomy Application to OP

Bone responds to two main forces:

o Gravity/weightbearing forces

o Muscle resistance/pull

Asymmetrical weightbearing forces on thoracic vertebral

bodies often lead to wedging fractures & cascade

No muscles attach to the body of thoracic vertebrae….

It shouldn’t be surprising that:

Anatomy + Mechanics biases thoracic vertebral bodies

for fractures!

3

• Height loss

• Upright posture becomes impossible (increased kyphosis)

• One thoracic vertebral fracture = 9% loss of forced vital capacity (breathing difficulties)

• Protruding abdomen Distension, constipation, digestive issues, loss of appetite

• Increased risk of death

• Vertebral fracture increases the risk of hip fracture 2-3x; and overall risk of having another vertebral fracture is 4x

Consequences of

Vertebral Fractures

It is the most common fracture that occurs as a result of osteoporosis. Ioannidis et al 2009

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• More muscle co-contraction, leading to more vertebral loading more fractures

• Increased chance of more vertebral fracture and more kyphosis

• Increased sway…or poorer balance reactions more falls

Consequences of Increased

KYPHOSIS

Katzman, et al., 2010;

de Groot et al., 2014

Greig, et al., 2014

3

Supine lying

Implications 3

Implications:

Movement Guidelines

• SPINE MOVEMENTS should minimize:

REPEATED/SUSTAINED, WEIGHTED,

END-RANGE, RAPID/FORCEFUL or COMBINED:

• Flexion/Rotation/Side Bending

– Reduce the cumulative effect of flexion/slouching/rotations (ADLs & Work ergonomics)

– Improved awareness/ergonomics for lifting/lowering heavy loads

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What therapeutic goals should

be targeted for individuals with

osteoporosis?

PREVENT FRACTURES via:

1) fall prevention:

– mobility, dynamic balance, muscle strength, postural

alignment

2) safe movement:

– postural alignment and body mechanics to protect the

spine

– muscular endurance in spinal extensors

– stretch muscles restricting mobility or optimal alignment

3) prevention of further bone loss:

– exercise may not have a guaranteed effect on bone

mineral density

4

Giangregorio LM, et al. Osteoporos

Int 2014; 25: 821-835

Exercise Frequency Examples/Comments

Strength Training ≥ 2x/week

• Exercises for legs, arms, chest, shoulders, back

• Use body weight against gravity, bands, weights*

• 8-12 repetitions maximum per exercise

Balance Training ~ 20mins daily

• Standing still: one-leg stand, semi-tandem stance, shift weight

between heels and toes while standing

• Dynamic movements: Tai Chi, tandem walking, dancing

• Progress from standing still to dynamic

Aerobic physical

activity

≥ 5x/week

(30min/day)

• Do bouts of 10 min or more

• Accumulate ≥ 30 min per day

• Moderate- or vigorous-intensity (5-8 on 0-10 Borg scale)*

Posture/ Back

Extensor Training

5-10mins

daily

• Lie face up on firm surface, knees bent, feet flat. Use pillow

only if head doesn’t reach floor. Do this 5-10 min/day.

• Progressions 1) lying with gentle head press, without changing

chin position, perform 3-5 seconds “holds”; 2) Erector spinae

activation in standing

Spine Sparing

Strategies

During daily

activities

• Learn a “hip hinge” and “step to turn” so that you can modify

activities that flex (bending forward) or twist spine

Exercise and Activity

Recommendations

*In presence of vertebral fracture, emphasize good alignment, and moderate over vigorous intensity aerobic

activity and consult Bone Fit trained Physical Therapist

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What’s so important about

daily spine sparing?

10-fold increase in

compressive forces on

anterior portion of

vertebral bodies

ANTERIOR WEDGING & FRACTURE

DEVELOPMENT OF POSTURAL HyperKYPHOSIS

Habitual slouching posture, repetitive lifting, or ADLs

which encourage flexion of spine

More loading on

vertebral bodies

More postural

sway & falls

MORE FRACTURES &

Morbidity/mortality

4

Teach “spine sparing” during ADL

and physical activity…. How?

• Utilize a hip hinge and/or Modified

Golfer’s Reach for many ADLs and

work needing spinal flexion

• Limit lifting from or lowering to the floor

• Support trunk when flexing

• Hold weight close to body, not overhead

• Minimize sustained sitting or slouched

postures

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Using a

Modified

Golfer’s

Reach

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Using Anatomy &

Mechanics to Rehabilitate

1. Remember & apply your

anatomy knowledge

2. Address the known tight/weak

muscle groups

3. Think about load & transitions

4. Treat to target

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Treat to Target

Client with OP & ‘poor posture’

Is the poor posture:

o Fixed? Flexible?

o Scapular girdle protraction alone?

o Combined scapular & thoracic?

o Likely to be exacerbated by

work/ADLs?

o A muscular strength or endurance

issue?

o What is the most likely successful

exercise prescription they will DO?

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General Guidelines

Postural Change Target o Scapular protraction Supf. Muscles

o Thoracic hyperkyphosis Erector Spinae

o Scapular & T spine changes Supf & Erector group

o Shoulder Impingement/

‘Frozen Shoulder’ Look at T Spine

5

Back Extensor Training

Daily for 5-10 min

• Perform 3-5 exercises and repeat 5-8 times; hold

each repetition for 3 seconds

• Can perform different exercises or the same

exercise in different positions (preferably lying flat

standing sitting)

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Back Extensor Training

Examples: 2 in 1

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In your practice, consider:

• Do you assume fractures and postural and height

changes are ‘normal’?

• Do you incorporate safe movements* into your

treatment and exercise programs?

• Do you give preventative ‘homework’ for your

client’s ADLs?*

(*refer back to slide on movement guidelines)

How will you individualize treatment to reduce falls

and fractures?

5

FINAL THOUGHTS

Encourage attention to posture, exercises for back extensor muscles daily

Instruct on spine sparing strategies for ADLs, fun & work to ↓ spine loads

Teach clients how to move instead of how not to move

Q & A 6

o www.osteoporosis.ca

o www.bonefit.ca

o https://www.iofbonehealth.org/

o https://www.facebook.com/toofit.tofracture/