Upload
amogh
View
226
Download
0
Embed Size (px)
Citation preview
8/18/2019 Current Concepts in Lumbar Spine
1/57
© Physioseminars 2009
7/10/200
8/18/2019 Current Concepts in Lumbar Spine
2/57
© Physioseminars 2009
7/10/200
Anatomy of the Spine
Concentric layers of annulus fibrosus.
Surrounding incompressible nucleus pulposus.
Nucleus acts to distribute pressure evenly.
It behaves hydrostatically.
Post-lateral annulus is the weakest, not as firmly
attached to vertebral end plate, no cover of PLL(Edwardset al 2001)
Anterior compression caused by flexion squeezes thenucleus backwards, and conversely extension forces itforwards.
8/18/2019 Current Concepts in Lumbar Spine
3/57
© Physioseminars 2009
7/10/200
Flexion Extension
Inter vertebral disc iscompressed anteriorly.
Size of the vertebral canaland IV foramen
Displacement of nucleusposterior.
Intra pressure is
Spinal cord & nerve rootsare stretched.
Inter vertebral disc iscompressed posteriorly.
Size of the vertebral canaland IV foramen
Displacement of nucleusanterior.
Intra discal pressure is Spinal cord & nerve roots
are stretched.
Nucleus pulposus
Annulus fibrosus
Facet joints
Ligaments
Muscles Nerve
Synovium
8/18/2019 Current Concepts in Lumbar Spine
4/57
© Physioseminars 2009
7/10/200
On loading, fluid is expelled from the annulus fibrosis andgoes into the nucleus pulposus
Centripetal fluid shift
8/18/2019 Current Concepts in Lumbar Spine
5/57
© Physioseminars 2009
7/10/200
Intradiscal mass displacement-non physiologicaldisplacement of tissues within the disc.
Protrusion-The displaced material causes a bulge in the intactwall of the annulus .(Hydrostatic Mechanism intact)
Extrusion-the disc material is displaced through the rupturedannular wall .(Hydrostatic Mechanism not intact)
Sequestration- a discrete fragment of disc material is forcedthrough the ruptured annular wall into the spinal canal.(Hydrostatic Mechanism not intact)
8/18/2019 Current Concepts in Lumbar Spine
6/57
© Physioseminars 2009
7/10/200
Age/Occupation
Functional Disability /Base lines measures
Where is the location of the pain? (body Chart)
Duration
Is the pain constant or intermittent?
Onset
What positions or movements increase/decreasethe pain?
Past history of back pain
Diagnostics Sleep position and patterns, seated positions and
postures
Assessment of the Spine (History/ Interview)
8/18/2019 Current Concepts in Lumbar Spine
7/57
© Physioseminars 2009
7/10/200
Bladder /bowel involvement, Saddleanaethesia,sciatica⇒ Cauda equina
Unexplained weight loss, Nocturnal pain H/O ofcancer⇒ Cancer
Trivial trauma in individual with osteopenia⇒Fracture
Systemically unwell ,febrile episodes⇒Spinal Infection
Exacerbations and remissions, marked morning
stiffness,raised ESR ,Persisting limitation allmovements⇒ Ankylosis Spondylitis
Waddell signs: Presence of nonorganic signssuggesting symptom magnification and
psychological distress◦ Superficial or nonanatomic distribution of tenderness
◦ Nonanatomic or regional disturbance of motor or sensoryimpairment
◦ Inconsistency on positional SLR
◦
Inappropriate/excessive verbalization of pain or gesturing◦ Pain with axial loading or rotation of spine.
◦ Give-away weakness: Inconsistent effort on manualmotor testing with “ratcheting” rather than smoothresistance
8/18/2019 Current Concepts in Lumbar Spine
8/57
© Physioseminars 2009
7/10/200
8/18/2019 Current Concepts in Lumbar Spine
9/57
© Physioseminars 2009
7/10/200
8/18/2019 Current Concepts in Lumbar Spine
10/57
© Physioseminars 2009
7/10/200
1
8/18/2019 Current Concepts in Lumbar Spine
11/57
© Physioseminars 2009
7/10/200
C/o pain in back&neck
8/18/2019 Current Concepts in Lumbar Spine
12/57
© Physioseminars 2009
7/10/200
1
1.Active Movements
A) Flexion
B) Extension
C) Lateral Flexion
D) Rotation Side glide
2.Repated Movement testing by McKenzie system.
3.Palpation
–muscles and fascia for increased tone andtrigger points.
4.Special Tests
a) Straight leg raise/slump test
b) SI joint test-Should be tested after ruling out L-Spine
c) Neurological examination
5.Muscles sling assessment.
6 Muscle imbalances Use Kendall’s guidelines
8/18/2019 Current Concepts in Lumbar Spine
13/57
© Physioseminars 2009
7/10/200
1
Straight Leg Raise◦ Indication-C/o of pain and other symptoms in the
posterior & lateral aspect of the lower quarter.◦ Test -Hip Flexion with a straight knee
Structural VariationProximal symptoms-use dorsiflexion
Distal symptoms-Hip flexion producing distal symptoms.
Active neck flexion not recommended.
Sensitizing movements
1) Internal rotation and adduction of hip.2) Dorsiflexion/eversion (tibial Nv bias)
3) Dorsiflexion/inversion (sural Nv bias)
4) Plantarflexion/inversion (peroneal Nv bias)
Slump Test
Indications-Headaches, pain in spine or pelvis &lower limbs.
Test
1. Thoracic & lumbar flexion
2. Cervical flexion
3. Knee extension
4. Dorsiflexion
Structural differentiationProximal symptoms-use dorsiflexion
Sensitizing Movement
1)C/L lateral flexion
2)Hip Internal Rotation & adduction
3) Foot movements for each nerve
8/18/2019 Current Concepts in Lumbar Spine
14/57
© Physioseminars 2009
7/10/200
1
Indication of the endurance of key muscle groups Bridge test are functional, they assess strength, muscle strength,
and ability of the athlete to control the trunk by the synchronousactivation of many muscles.
4 Tests-
1) Prone Bridge
2) Lateral Bridge
3) Flexion Endurance test
4) Extension Endurance Test
8/18/2019 Current Concepts in Lumbar Spine
15/57
© Physioseminars 2009
7/10/200
1
Men Women
Extension 161 185
Flexion 136 134
Right side bridge 95 75
Left side bridge 99 78
Flexion/extensionratio
.84 .72
◦ FABER tests
FABER or Patrick’s test is used to assess hip or SI joint dysfunction
8/18/2019 Current Concepts in Lumbar Spine
16/57
© Physioseminars 2009
7/10/200
1
Iliotibial BandStretch Test◦ Test will often
provoke pain inthe contralateralPSIS areaindicating and SIproblem
◦ SI dysfunction canlead to a
shortening of theIT-Band and aperpetuation orreoccurrence ofthe problem
Neurological Exam◦ Sensation Testing
If there is nerve root compression, sensation canbe disrupted
8/18/2019 Current Concepts in Lumbar Spine
17/57
© Physioseminars 2009
7/10/200
1
◦ Reflex Testing
The two reflexes to be tested in the lower extremityare the patellar tendon and Achilles tendonreflexes
Used to assess the L4 and S1 nerve root respectively
8/18/2019 Current Concepts in Lumbar Spine
18/57
© Physioseminars 2009
7/10/200
1
Indahi A,et al: Good prognosis for low back pain when left untampered. Arandomized clinical trail. Spine 20:473-477,1995
Van den Hoogen HJM,et al :The prognosis of low back pain in generalpractice.Spine 22:1515-1521,1997
8/18/2019 Current Concepts in Lumbar Spine
19/57
© Physioseminars 2009
7/10/200
1
Boden SD,Wiesel SW:the multiply operated low back patient. In The Spine (ThirdEdition ). Eds : Rothman RH, Simone FA, W.B. Saunders Co., Philadelphia,1992
In a study on blue collar workers, isometric lifting strength was of no
predictive value for the future reports of the low back pain across thesexes, and in male workers, greater strength was actually associatedwith more frequent reports of low back pain (Batte M,et al :Spine
14;851-856,1989)
8/18/2019 Current Concepts in Lumbar Spine
20/57
© Physioseminars 2009
7/10/200
2
FALSE: Comparison of patients with herniated lumbar discs to controls found no difference inexercise history during the time preceding onset of injury (Brennan G: Spine 12:699-702,1987)
In another study , frequent physical exercise actually showed borderline significance as a riskfactor for sciatica (Riihimaki H: Spine 19 138-142,1994)
-Mechanical Diagnosis& therapy (McKenzieSystem)
-Movement impairment syndromes- Sarhman
-Motor control impairment –O’Sullivan &
Dankaerts-Muscle imbalance- Janda
-Quebec Task Force-pain patterns
8/18/2019 Current Concepts in Lumbar Spine
21/57
© Physioseminars 2009
7/10/200
2
DerangementSyndrome
Other
Posture SyndromeDysfunctionSyndrome
ScoliosisLumbar canal stenosisSpondylolisthesis
SI joint Vs L-spine Vs HipFacet joint syndromeChronic pain state
8/18/2019 Current Concepts in Lumbar Spine
22/57
© Physioseminars 2009
7/10/200
2
8/18/2019 Current Concepts in Lumbar Spine
23/57
© Physioseminars 2009
7/10/200
2
Long A, Donelson R,Fung T:Does it matter which exercise ?A randomizedcontrolled clinical trail of exercise for low back pain.Spine 29:2593-2602,2004
8/18/2019 Current Concepts in Lumbar Spine
24/57
© Physioseminars 2009
7/10/200
2
Most prevalent of the McKenzie’s mechanical subgroups.
Derangement means some disruption in joint articulation.
Characteristic signs are that of rapid changes in both jointsmechanical behavior and its symptoms.
Rapidly reversible LBP-Ron Donelson
One direction makes pain better and the opposite direction oftesting aggravates the pain e.g. lumbar flexion worsens thelumbar symptoms, extension testing will usually centralizeand abolish the same pain.
Clinical presentation includes worsening or peripheralisationof the symptoms in response to therapeutic loading
strategies Clinical pattern is variable
May have history of previous episodes
Signs and symptoms may be either somatic ,radicular or acombination. Patients with sciatica ,including many withneurological loss attributed by nerve root compression from aherniated disc, typically fall in this group
Symptoms may be constant or intermittent
May more proximally or distally
Repeated movements cause symptoms to increase/decrease,centralize /peripheralise,produce/abolish
Mechanical presentation always includes reduced ROM oracute deformity in a either forward (kyhotic) or lateral/Lateralshift (Scoliotic) direction.
Loading Strategies can cause lasting changes
Treatment-Reductive forces applied to reduce, abolish orcentralize symptoms
8/18/2019 Current Concepts in Lumbar Spine
25/57
© Physioseminars 2009
7/10/200
2
Intermittent pain that is reproduced only when patient movesto their lumbar end range in a specific direction
It is consistent with the presence of painful, adaptivelyshortened tissues that are a result of contracture or scarringfrom the prior injury or surgery
Repeated movement will produce symtoms,which do notpersist after testing
Midline LBP without radiation and painful restriction of theend range
Present for atleast 6-8 weeks
Treatment-Remodelling program consists of stretchingexercises several times per day over several weeks tolengthenand remodel them so they they no longer limitmovement.
Smaller subgroup
Intermittent pain limited to LBP, no radiation
Produced only with prolonged positioning and loading of thespine at, or near end- range, usually in flexion
Prolonged slouching is by far the most common cause of thispain
Pain abolished by patient moving out of that end-rangeposition.
Repeated movement testing- No loss of lumbar motion, nodeformity and no pain with any direction of testing.
Treatment –Education and posture correction
8/18/2019 Current Concepts in Lumbar Spine
26/57
© Physioseminars 2009
7/10/200
2
Centralization
It is a clinical phenomenon frequently observed duringmechanical evaluation of patients with low back painsyndromes. Centralization as defined by McKenzie, describesa situation in which the pain arising from the spine and feltlaterally from the midline or distally is reduced andtransferred to a more central or near midline position ,itoccurs in response to repeated movements or sustainedpostures.(23)
Useful for patient classification.
Prognostic value for identifying patients who will respondfavorably to conservative rehabilitation.
Directional Preferenceis the direction of the movement orposture (Flexion , Extension , or side-glide/rotation) thatproduces the centralization phenomenon.
Long et al demonstrated that patients with a mechanically
determined directional preference achieved superior
outcomes when the exercises and evidence-based advice
matched the individual’s directional preference compared to
exercise protocols unmatched to directional preference and
evidence-based advice.(24,25)
McKenzie introduced the concept of direction- specificexercises aimed at producing an analgesic effect for personswith LBP
8/18/2019 Current Concepts in Lumbar Spine
27/57
© Physioseminars 2009
7/10/200
2
C/o of pain on the right side of back and buttock
Same day after shift correction –pain reduced
8/18/2019 Current Concepts in Lumbar Spine
28/57
© Physioseminars 2009
7/10/200
2
55
History: Sudden, partial or complete loss of voluntary
bladder function due to massive disc impingementon spinal nerves
Saddle Anesthesia
Urinary retention and bilateral sciatica
Treatment: Surgical Emergency- decompression is mandatory
for prevention of irreparable / irreversible bladder
damage 12 hoursis the maximum time prior to irreversible
changes
Disease of older people
Caused by bone( facets,osteophytes) or soft tissues(bulgingdisc, ligamentam flavum enlargement)
Neurogenic Claudication,Numbness and tingling
Trial of conservative,nonsurgical treatment.
If intolerable ,MRI/CT and possible Laminectomy
Two directional subgroups
1) Pain improved when seated or spine is flexed.
2) Pain improved with performing end-range Lumbarextensions.
8/18/2019 Current Concepts in Lumbar Spine
29/57
© Physioseminars 2009
7/10/200
2
57
Spondylolysis: Anatomic defect in the bony pars interarticularis
within the lamina
May uni- or bilateral
Can be congenital or induced
Usually without clinical symptoms with incidentalfindings on radiographs
Spondylolyisthesis
Progression of spondylolysis with separation Grades assigned I-IV for level of translation
Most common levels are L5-S1 (70 ) and L4-L5 (25 ) May be asymptomatic, but can result in
Spondylosis/DDD/Radiculopathy
Rule out Lumbar Spine
Is it SI joint – presence of at least three out of fivepain provocative SIJ tests (Mark Laslett , Aprill2003,Australian journal of physiotherapy)
Yes No
Treat Assess Hip
8/18/2019 Current Concepts in Lumbar Spine
30/57
© Physioseminars 2009
7/10/200
3
Gaenslen’s test
Compression test
Distraction test
Thigh thrust test
“Based on our review, there are fewdata to support the use of symmetry ormovement tests in the identification ofwhat has been considered SIJdysfunction. In addition, the results ofradiographic studies suggest that the
motion at this joint is too small toaccurately assess with visualestimation and palpation.” Conclusionwas to use the above pain provocationtests to identify SIJ dysfunction.
Ferburger, Janet, Riddle ,Daniel, “UsingPublished evidence to guide theexamination of the SI joint region",Physical Therapy,81,5 ,May 2001
Sacral thrust test
8/18/2019 Current Concepts in Lumbar Spine
31/57
© Physioseminars 2009
7/10/200
3
Pain generating mechanism influenced by psychologicalfactors or neurophysiologic changes peripherally or centrally
Persistent widespread pain
Aggravation with all activity
Exaggerated pain behavior
Inappropriate beliefs and attitudes about pain
Young S, Aprill C: Characteristics of a mechanical assessment for chronic lumbarfacet joint pain .J Manual and Manipulative Therapy 8: 78-84,2000
8/18/2019 Current Concepts in Lumbar Spine
32/57
© Physioseminars 2009
7/10/200
3
THE McKENZIE METHOD CATEGORIZESPATIENTS INTO MEANINGFUL
SUBGROUPS
FOR THE PURPOSE OF PRESCRIBINGAPPROPRIATE THERAPEUTIC
INTERVENTIONS
Danish Institute for Health Technology Assessment. Low Back Pain. Frequency, Managementand Prevention from an (sic)HTA Perspective.Danish Health Technology Assessment 1999 1 (1)
8/18/2019 Current Concepts in Lumbar Spine
33/57
© Physioseminars 2009
7/10/200
3
2)Movement Impairment syndromes(Sahrmann)
Lumbar rotation-extension syndrome
Lumbar extension syndrome
Lumbar rotation syndrome
Lumbar rotation-flexion syndrome
Lumbar flexion syndrome
3) Motor Control impairment (O’ Sullivan)
Flexion pattern
Flexion/lateral shifting pattern
Active extension pattern
Passive extension pattern Multidirectional pattern
8/18/2019 Current Concepts in Lumbar Spine
34/57
© Physioseminars 2009
7/10/200
3
Provocative movements :Flexion , slump sitting. Pain relief: Standing, Prone lying , lean forward at hips
Tests
-Forward bend-↑ pain , most movement at spine
Impairments
-↑ stiffness of hamstrings , abdominals(RA)
-↓ stiffness of paraspinal
Treatment
-Correct posture
-Move at hips rather than spine
-Train control of paraspinal muscles
Provocative movements: Lumbar extension
Pain relief : Flattening of lumbar spine,↓ Hip flexor activity
Tests: ↑ pain during tasks involving extension
-Forward bending-↓symptoms
-Return from flexion-↑symptoms-ext early
-Supine-↓symptoms with knee bend
-Quadruped-Forward ↑ pain
Impairments- ↑ stiffness of hip flexors and ES
- ↓ stiffness of abdominals and gluteus maximus
Management
Correct and control lumbar lordosis
-Improve abdominal muscle control of rotation
-Improve hip flexor length
8/18/2019 Current Concepts in Lumbar Spine
35/57
© Physioseminars 2009
7/10/200
3
Pain relief: Prevent lumbar rotation/LF
Tests:-Lateral Flexion-asymmetric
-Single leg stance-poor truck control
-Rocking back in quadruped
Impairments
-More flexible into rotation/lat flexion at lower segments than upper
Provocative movements: Rotation +/-lateral flexion
-↑stiffness of paraspinal ,Hip abductors
-↓stiffness of abdominal
Management
-Prevent rotation in low lumbar spine
-Identify tasks that include rotation
-Maximise rotation at hips
-Train control during movement tasks-quadruped control rotation
Provocative movements: Lumbar extension and rotation and limbmovement that produce these movements .
Pain relief: Flexion( eg stand with spine against the wall) Tests-Forward bending- Reduces pain, but extended early on return-Lateral flexion,rotation,single leg stance-asymmetric and poor
control.-Hip extension in prone Impairments
-Spine flexible into extension & rotation- ↑ stiffness of hip flexors ,hip abductors, lat dorsi- ↓ stiffness of abdominal muscles.- Dominant activity of extensor and hip flexor muscles- Oblique abdominals may be weak. Treatment-Control extension of lumbar spine• Improve abdominal control• Reduce tightness of hip flexors
8/18/2019 Current Concepts in Lumbar Spine
36/57
© Physioseminars 2009
7/10/200
3
Provocative movements: Flexion & rotation-sitting(slump),bending,twisting
Pain relief: Prevention of flexion/rotation, prone lying
Tests:
-Forward bend-most movement of lumbar spine-pain
-Rotation-asymmetric
Impairments
-Hang on OE in sway back
-↑ stiffness of hamstrings
-↓stiffness of back extensors
Treatment
- Improve abdominal muscle control of rotation- Improve paraspinal to control lordosis
Key Components & Progressions1)Education
2)Posture Management-Ergonomics
3)Mobilization/Manipulation/Neuralmobilization
4)Specific Exercise- Directional Preference5)Core Stability
6)Specific Stretch and Strengthening
7)Prophylaxis
8/18/2019 Current Concepts in Lumbar Spine
37/57
© Physioseminars 2009
7/10/200
3
Outcome
Treatment
Diagnosis
Assessment
Subjective pain ratings
Duration/Pain location/Severity
Back and leg pain Intensity
Oswestry score
Roland-Morris
Return to work status
Medication used Activity Interference
Lifting capacity
Return to work status
Self rated improvement-In %
Nottingham health profile
8/18/2019 Current Concepts in Lumbar Spine
38/57
© Physioseminars 2009
7/10/200
3
Centralization (McKenzie)
Appears to identify a substantial subgroup ofspinal patients.
It is a clinical phenomenon that can be reliablydetected, and is associated with a good prognosis.
Negative Extension Sign (Herbert Alexander) A positive extension sign was defined as an
increase in radicular pain on attempted passive
lumbar extension
Alexander AH et al: Nonoperative management of herniated nucleus pulposus : patientselection by the extension sign .Long-term follow –up.Orthop Rev 21:181-188,1992
8/18/2019 Current Concepts in Lumbar Spine
39/57
© Physioseminars 2009
7/10/200
3
STAGE 1 – Reducing the derangement
Posture education
Core muscle recruitment
Stretching of the shortened tissues
DURATION – 1-4 WEEKS
STAGE 2
MAINTAINENCE OF DERRANGEMENT
IMPROVING THE CORE STABILITY
POSTURE MAINTAINENCE
DURATION 2-4WEEKS
8/18/2019 Current Concepts in Lumbar Spine
40/57
8/18/2019 Current Concepts in Lumbar Spine
41/57
© Physioseminars 2009
7/10/200
4
Office of Horrors
http://e/My%20Documents/Safety%20talk%201.ppthttp://e/My%20Documents/Safety%20talk%201.ppt
8/18/2019 Current Concepts in Lumbar Spine
42/57
© Physioseminars 2009
7/10/200
4
Monitor -20-40” Monitor height-
eye level. Keyboard Mouse Chair Desk Telephone Lighting
8/18/2019 Current Concepts in Lumbar Spine
43/57
© Physioseminars 2009
7/10/200
4
There are a variety of exercises that can beperformed
8/18/2019 Current Concepts in Lumbar Spine
44/57
© Physioseminars 2009
7/10/200
4
Should be routinely incorporated into therehab program
Used to reinforce pain-reducing movementsand postures
Extension exercises◦ Should be used when pain decreasing w/ lying down
and increases w/ sitting◦ Backwards bending is limited but decreases pain --
forward bending increases pain
◦ STLR is painful
Flexion Exercise◦ Used to strengthen abdominals, stretch, extensors
and take pressure off nerve roots
◦ Pain increases with lying down and decreases withsitting
◦ Forward bending decreases pain
◦ Lordotic curve does not reverse itself in forward
bending PNF Exercises
◦ Chopping and lifting patterns can be used tostrengthen the trunk, re-establish neuromuscularcontrol and proprioception
8/18/2019 Current Concepts in Lumbar Spine
45/57
© Physioseminars 2009
7/10/200
4
Must re-educate muscles to contractappropriately
Stabilization exercises can help minimize thecumulative effects of repetitive microtrauma
Core/Dynamic stabilization
◦ Control of the pelvis in neutral position
◦ Integration full body movements and lumbarcontrol
◦ Incorporation of abdominal muscle control iskey to lumbar stabilization
8/18/2019 Current Concepts in Lumbar Spine
46/57
© Physioseminars 2009
7/10/200
4
8/18/2019 Current Concepts in Lumbar Spine
47/57
© Physioseminars 2009
7/10/200
4
8/18/2019 Current Concepts in Lumbar Spine
48/57
© Physioseminars 2009
7/10/200
4
•Pelvic Floor muscles•Transversus Abdominis•Multifidus•Diaphragm
Attachments
-Lateral raphe of the the
thoracolumbar fascia
-Lateral 1/3 of the inguinal
ligament
-Iliac crest-Lower 6 costal cartilage
interditating with the costal fibers
of the diaphragm
8/18/2019 Current Concepts in Lumbar Spine
49/57
© Physioseminars 2009
7/10/200
4
Role
Contraction increases intra-abdominal pressure.
Assists with spinal mobility.
Aids in increasing the stiffness value of the thoracolumbar fascia by itscontraction thereby allowing effective transference of the force through thespine.
Stabilizes the sacroiliac joint through tension generated in the posteriorsacroiliac ligaments( Lee,D.1999).
Provides a “hoop effect” around the midsection of the body.
Allows primary muscles for lumbar stability.
Is active in all planes of movement.
Pubococcygeus
Puborectalis
Ilicoccygeus
Ischiococcygeus
Role of the Pelvic Floor(Snapsford,1998)
-Unloading the spine
-Pelvic-Spinal stability
-Increased intra-abdominal pressure
-EMG studies show a correlation between pelvic floorand abdominal muscle contraction(Snapsford,Hodges,Richardson,1998)
8/18/2019 Current Concepts in Lumbar Spine
50/57
© Physioseminars 2009
7/10/200
5
Coativation Pattterns -Pubococcygeus w/
Transversus Abdominis
-Puborectalis w/RectusAbdominis
-Iliococcygeus &Ishiococcygeus w/Obiliques.
Note
-Ischiococcygeus inserts
sacrospinous ligaments
-It is a dynamic stabilizer ofthe posterior sacroiliac joint.
Note:The fillingthe fascialenvelop’ effects stiffens thethoracolumbarfascia,contributing to the“hoop effect of the
transversus”
8/18/2019 Current Concepts in Lumbar Spine
51/57
© Physioseminars 2009
7/10/200
5
Largest and most medial muscle of the lumbar muscles.
Polysegmental with separate bands which receive their owninnervation.
A study (Hives,1994) found evidence of lumbar multifidus localinhibition at the pathological segment with acute and subacute lowback pain.
The contraction of the multifidus adds to the stiffness value of thethoracolumbar fascia by filling up the fascial envelop formed betweenthe spinous process and the transverse processes on either side.
Although it is primarily an extensor of the lumbar spine,in standing itprimarily acts to resist anterior shear and flexion.
The multifidus and the psoas major form a force couple to square thelumbopelvic unit in the sagittal plane (Porterfield,Derosa 1991)
Similarly the multifidus and pelvis floor muscles act as a force coupleto check sacral nutation and counternutation in the sagittal plane(Lee,1998)
Sternal origin-Xiphoid Process
Costal origin-Last six ribs and costal cartilages.
Lumbar origin-1st ,3 or 4 lumbar vertibrae
All inserting radially on the central tendon
It is interesting to note that the crura of the diaphragm blendinto the psoas major inferiorly.
The TA interdigitates with the diaphragm as well.
The TA and the pelvic floor muscles work in a synergy.
It also acts as a passive restraint when increases in intraabdominal pressures as in weight lifting push the abdominalcontent superiorly.
It is interesting to note that the diaphragm significantlycontributes to the lumbarspine stability via the cruralattachments,during the sustained loading of the spine(Hodges2000)
8/18/2019 Current Concepts in Lumbar Spine
52/57
© Physioseminars 2009
7/10/200
5
Lateral System
1. Ipsilateral Hipabductors
2. ContralateralHip adductors
Left side lying to test rightlateral sling .Abduct theright leg.
Insufficient recriutment ofthe gluteus medius
The posterior fibers ofgluteus medius arepalpated during the lateralloading of the leg inabduction and externalrotation.
8/18/2019 Current Concepts in Lumbar Spine
53/57
© Physioseminars 2009
7/10/200
5
Deep LongitudinalSystem
1. Biceps Femoris2. Sacrotuberous
Ligaments3. Thoracolumbar
Fascia
4. Deep ErrectorSpinae
8/18/2019 Current Concepts in Lumbar Spine
54/57
© Physioseminars 2009
7/10/200
5
AnteriorObilique System
1. IpisilateralExternalObiliques
2. ContralateralInternal Obiliques
3. Abdominal Fascia4. Contralateral Hip
adductors
A Sequenced curl up tests the
oblique abdominal portion of
the anterior oblique slings
bilaterally.
Bilateral overactivation of the
obilque abdominals will narrow
the infrasternal angle.
8/18/2019 Current Concepts in Lumbar Spine
55/57
© Physioseminars 2009
7/10/200
5
PosteriorObilique System
1. IpsilateralLatissimus Dorsi
2. ThoracolumbarFascia
3. ContralateralGluteus Maximus
Test for lower part of
posterior oblique sling
Concentric action of
Gluteus maximus
Test for upper part of
posterior oblique sling
Test for Lat Dorsi and Right
post oblique sling
8/18/2019 Current Concepts in Lumbar Spine
56/57
© Physioseminars 2009
7/10/200
5
8/18/2019 Current Concepts in Lumbar Spine
57/57
© Physioseminars 2009
7/10/200
Muscles that can adversely affect the biomechanics of thelumbo-pelvic region
Lattismus Dorsi
Errector Spinae
Oblique Abdominals
Hamstring
Psoas Major
Rectus femoris
TFL
Short and long adductors Piriformis/Deep external rotators of the hip
Progression of stabilization exercises shouldmove from supine activities, to proneactivities, to kneeling and eventually toweight-bearing activities
Stabilization exercises must be thefoundation and should be incorporated intoeach drill