CONSIDERATIONS FOR SPINAL REHABILITATION

DinoPinciotti,PTDirectorofCenterforRehabilitation

andSportsExcellenceUniversityOrthopedicAssociates

EVIDENCE BASED REHABILITATION OF THE LUMBAR

SPINEDinoPinciotti,PT

DirectorofCenterforRehabilitationandSportsExcellence

UniversityOrthopedicAssociates

I have nothing to disclose or have any financial interest.

Learning Objectives

• Beabletodefinetheterm“core”withregardtocorestabilityandcoretraining

• BeabletodescribeandunderstandthedifferencebetweenMicrotrauma andMacrotrauma

• Understandcomponentsoffunctionalapproachtokineticchainrehabilitation,includinghowthecoreaffectsboththeUE’sandLE’s.

• Howthecorefunctionstomaintainposturalalignmentandachievedynamicstabilityduringallfunctionalmovementsinathletes.

Learning Objectives

• Understandtheappropriatesequencingofexercisesforcorestabilizationtraininginvarieddevelopmentalpostures,usingavariedtypesofresistance,andwithspecificapplicationsforimposeddemandsforavarietyofathletes/sports.

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Red Flag

• SignsandSymptomsfoundinthepatienthistoryandclinicalexaminationthatmaytieadisordertoaseriouspathology

• Sometimesisidentifiedasafindingthatisreflectiveofadelayedorpooroutcome.Wecallthisaprognosticredflag

• SizerP,Brismee JM,CookC.Medicalscreeningforredflagsinthediagnosisandmanagementofmusculoskeletalspinepain.PainPract.2007.

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Red Flags – Non-mechanical Spinal

• Prevalence(1%)–Multiplemyeloma,breast,lung,prostrate,kidney,lymphoma/leukemia,spinalcord,

• Neoplasia(0.7%)– Osteomyelitis,paraspinous abscess,epiduralabscess,shingles

• Infection(0.01%)– AnkylosingSpondylitis,psoriaticspondylitis

• InflammatoryArthritis(0.3%)

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Red Flags - Visceral

• Prevalence(2%)• AorticAneurysm• Pelvic:Prostatitis,endometriosis,• Renal:Nephrolithiasis,pyelonephritis,perinephricabscess

• GI:pancreatitis,cholecystitis,penetratingulcer.

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Clinical Guidelines

• PhysicalTherapist• AthleticTrainer• MassageTherapist• OccupationalTherapist• Physicians

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Etiology of Injury to the Spine in AthletesMacrotrauma

• Highvelocityinjuries– singleevent

• “inabilitytogeneratesufficientcorestabilitytoresistexternalforces”duringhighspeedevents

• Muscletears,strains,ligamentinjuries,bonyfractures……

Microtrauma

• Repetitive,lowlevelforces,overuse

• “Deficientenduranceofcorestabilizingmusculature”

• Posturalsyndromes• Spondylolysis,Spondylolisthesis,

discinjuries….

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TBC – Treatment Based Classification

1. SpecificExercise(Centralization)2. Mobilization(Clinicalpredictionrule)3. Immobilization(Nodecreaseinsymptomswith

anymovements)4. Traction(Radiculopathy– Decompression)

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Specific Exercise:

• Exercisethatcentralizes,reducessymptomsoraddressesthepatient’sconditionspecifically

• OftenreferredtoastheMDTapproach– akaMcKenzieapproach

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Immobilization:

• Strengthening(Stabilization)• Localandnon-specificstrengtheningexercises• Generalactivationexercises

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Specific Exercise Classification• LateralShift• Alateralshiftdoesnotautomaticallyimplicateadisc(PorterandMiller,1985)

• Correctthelateralshift- >Lookforcentralization• Centralizationhasbeenshowntobeaneffectivetreatmentforpositiveoutcomesinmultiplestudies(Werneke andHart1999and2001)

• Carry– OvertoHEPandfollowuptreatmentsessions– Proneonelbow,PronePressups,

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Mobilization ClassificationClinical Prediction Rule (CPR)

1. Durationofsymptoms<16days2. Hipinternalrotationofatleast35degrees3. Lumbarsegmentalhypomobilitytestedwithaspringtest4. Nosymptomsdistaltotheknee5. Scoreof<19ontheworksubscaleoftheFearAvoidance

BeliefsQuestionnaire6. Fourof5ofthesefindingsincreasestheoddsofashort

termpositiveresponsefrommanipulationby25foldanddemonstratedbetteroutcomesthanexercises.

Flynnetal.Aclinicalpredictionruleforclassifyingpatientswithlowbackpainwhodemonstrateshort-termimprovementwithspinalmanipulation.Spine(Phila Pa1976).2002;27(24):2835-43.

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Stabilization GroupStrengthening Group

• CPRforStabilization?• Doesthepatienthaveatleast3ofthefollowing:– AverageSLRROM>91degrees– PositiveProneinstabilitytest– Positiveaberrantmovements– Age<40yearsold

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Stabilization Group

• Improvemotorcontrolandsequencingoflocalstabilizers– TransversusAbdominus,Multifidi,andCoreStabilizers

– AmultiphaseApproach(Phases)

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Why focus on the Core in Athletes?

• RelationshiptofunctioninallADL’s,Sports!– Proximalstabilityfordistalmobility(KnottandVoss1968)

– Kineticchainrelationships(Dr.BenKibler etal.1998)

– RegionalInterdependence(Wainner etal.2007)

Importancefor“normals”ortheuninjuried- SportPerformance- Speed,Power,Force!

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Examples: Transmission of Forces

• BaseballPitcher– FromgroundtoLE’sthroughtrunkto

UEtoball– Velocity,location,rotationontheball,

anddeliveryofdifferenttypesofpitches

• Gymnast– ForcesfromapparatustoUE’s

throughtrunktopropelbodyinairbornepositions

– Conversionofhorizontalenergytoverticalspeed,position,andtrajectoryofbodythroughspace.

• Tennis– FromthegroundtoLE’sthroughtrunk

toUEthroughtheracquettotheball.– Velocity,location,spinofservedball,

varioustypesofserves.

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Why talk about the Core, Specifically in Relationship to Athletes?

• PatellofemoralDysfunction• ACLresearchandprevention• Anklesprains,distalmotorcontrol• Rotatorcuff/GHjointdysfunction• Scapulothoracic Dysfunction• LumbarDiscInjury• Spondylopathies– Prevention,wellness,performanceenhancementimplications!

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Functions of Core Muscles

• Stabilizeabodysegmentsoanothersegmentcangeneratepower– ProximalStabilityforDistalMobility

• ShockAbsorption• Maintainfunctionalpostures• DynamicMotion- AccomplishedbyCoremusculature

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Trunk/ Lumbar/ Pelvis

• Plentyofinjuriesintheseareasasaresultof:

• OveruseInjuries• MuscleImbalances• PoorBiomechanicalDysfunction

• ComplexRotationalMovementPatternsintheAthlete– AxialTwisting

• VeryDestructive• Lumbar-Pelvic-HipComplex– “TorqueConversion

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Axial Twisting – Protection = Co-contraction

• AxialTwistMovements– Resultsinacomplexpatternsofmuscleactivityinvolvingsubstantialco-contractionofrectusabdomensanderectorspinaemuscles,despitetheirlimitedpotentialtogeneratetwistingmovements.

• AthleticactivitiesthepowerisgeneratedbythehipswithastableTrunk

• Evaluationiscritical!

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Spinal Stabilization

• Whatisit?• Itiswhatathletesneedtohaveinthelumbarspinewhentheyareperformingtheiractivities

• Rotationalforcesinthelumbarspinearedestructivetotheathlete

• Cancausesevereproblems• Canevenendacareer

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What is Spinal Stabilization?

• Muscle“dysfunction”destabilizesthespine,reducestheroleofthefacetjointsintransmittingtheload,andshiftsloadstothediscandligaments.

• DynamicStabilization=Co-Contractionofmuscles• Inadditiontoaugmentingstabilityandjointstiffness,co-contractionalsocanservetoregulatethestressdistributionsduringjointcontact.

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Hip Muscles Protect and Improve Performance

• Lowerbackpain,pelvic,hipandlowerextremityinjuries– demonstratetightnessofthehipflexorsandweaknessoftheglutealmaximus.Posteriorfibersofthegluteusmedius andthedeepsixexternalrotators.

• Watkinsetal.demonstratedtheimportanceoftrunkandhipmusclesinstabilizingandcontrollingtheloadingresponseformaxpowerandaccuracyingolfer’s.

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Trunk as a Stable Cylinder• 4Wallsaroundthespine

– Diaphragm– PelvicFloor– TransverseAbdominis– Multifidi

• Needallforuprightpostures,stiffness

• Needtoincorporateallwallswithexerciseprograms!

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Local vs Global Musculature(Richardson, Jull, Hodges, Hides, 2004)

LocalMuscles(Postural,tonic,segmentalstabilizers)

• Intertranversarii andInterspinales

• Multifidi• TransverseAbdominus• QuadratusLumborum• Diaphragm• InternalOblique(post.Fibers)• PsoasMajor• **Hiprotators• **Hipabductors

GlobalMuscles(Dynamic,phasic,torqueproducing)

• RectusAbdominus• ExternalOblique• InternalOblique(ant.Fibers)• Longissimus• LatissimusDorsi• HipAdductors• HipExtensors• Quadriceps• Hamstrings• **Hiprotators• **Hipabductors• **Disagreementexistsabout

whetherthesearelocalorglobal

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Local Muscles: (Most Important)

• TransversusAbdominis• Multifidi• Muscularattachmentsofthoracolumbarfascia• Smallmusclesofhips/pelvis

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Transverse Abdominis

• DirectionofFibers:Horizontal

• Drawinginoftheabdominalwall

• Corestabilization• Stiffnessoftrunkcylinder• SIjointcompression/stabilization

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Multifidus

• Presentthroughoutthespinalcolumn,mostprominent(largestcrosssection)inlumbarregion

• Function:STABILIZATIONagainstrotationofspinetowardoppositeside

• Worksoppositethepsoasforlumbopelvicsagittalbalance.

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Multifidus

• Tonically activeduringwalkingandallanti-gravityactivitiesandUE/LEmotions

• Responsibleformorethan2/3ofthesegmentalstiffnessatL4-L5level

• Stabilizerratherthanprimemover– (Koviv,2004,Wilke,1995,Mirka

1993,Morris,1962)

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Intervention Considerations

• Again,ProximalStabilityforDistalMobility- Notanewconcept

• Byusingthecorestabilizerswecan:– CompletelyrehabilitateUEandLEinjuriesandreturntooptimalfunction

– Increaseforce/torquedistallybyusingthekineticchain– Increasepower/accuracyofUEandLEtasksbytransferofenergy

– Enhanceperformance!

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Core Training

• Beginwithlocalfocustotraincorestabilizingmuscles

• Thenaddlarger(global)musclesforperturbation,developmentofpower,dynamicfunction(allowmovement)

• Positions- Developmentsequence• Progresstounstablesurfaces• Thenprogresstoweightsorresistancebands

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Core Training

• Supine• Quadruped• SwissBall– MoreDynamic• Proneplanks• Sideplanks• ½Kneelingchopsandlifts(MB/T-Band/Isotonic)• Closedchain– SinglelimbDeadLift• Corestabilitywithclosedchainexternalrotation

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Endless Possibilities

• Limitedbyyourowncreativity• Lookatthescienceofmovement• MaketheexercisesFUNtional inanygivenposition…youmustpractice/trainintheposition….

• RemembertheSAIDPrinciple• (SpecificAdaptationsImposedDemands)

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Why Address the Core in the Athlete?

• EvidenceBased• SeetheBigPictureandtreatviatheentirekineticchain

• Everyathleteshouldbetrainingtheircore!• Preventre-injury,effectivelyretrainsportmovementstousecoreandproximalstabilizersefficiently!

• TraintheButtandGutt!

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In Summary:1. Evaluationisthekeytotreatingthelumbarspine2. Decidewhichofthe4categoriesfityourpatient

thebest.3. ManualTherapyandTherapeuticExerciseappears

tobethebestscenarioforthepatient4. FocusonCoreStabilizationTraining– everyone

needsitandthereiscarryovertoUEandLE5. FunctionalProgression6. Staticà DynamicMovements7. Simpletomorecomplexactivities

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Thank You!

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