Upload
maya-snyder
View
220
Download
0
Tags:
Embed Size (px)
Citation preview
Spine Stabilization ConceptsSpine Stabilization Concepts
J. Scott Bainbridge, MD
Denver Back Pain Specialists
www.denverbackpainspecialists.com
History of “Spine Stab”History of “Spine Stab”
1924 Von Lackum proposes that much back pain is caused by instability of spine
1944 Knutson notes that intervertebral disk degeneration leads to abnormal motion which he terms “segmental instability”
HistoryHistory
1980s “Neutral spine” concept introducedPosition of comfort where muscular support
reduces stress on painful structures (disc, facet, nerve, etc.)
1990 “dynamic stabilization” developed to be more functional – interest increased after Joe Montana returns to football after LB surgery
HistoryHistory
1996 – current: Back stabilization continues to evolve and become more sport and work specific
Quality research and educational efforts by Hodges, Richardson, Hides, Jull, Comerford and others
Popularization of ball, pool, Pilates, pulley and other exercise systems
MOTION SEGMENTMOTION SEGMENT
vertebral bodies intervertebral disc facet joint spinal canal foramina transverse process spinous process
FACET JOINTFACET JOINT
NEURAL STRUCTURESNEURAL STRUCTURES
cauda equina dura sheath DRG nerve root medial branch
Movement SystemMovement System
Articular
NeuralMyofascial
Connectivetissue
Pain MechanismsPain Mechanisms Nociceptive
– mechanical & inflammatory
Sensitisation– peripheral– central
autonomic
Behavioural / Psycho-social
PhysiologicalPhysiological Considerations Considerations The motor unit consists of
the neurone and the muscle fibres it innervates
All muscle fibres in a single motor unit are of the same fibre type
The maximal contraction speed, strength and fatigability of any muscle depends on the proportion of the three fibre types
(Vander et al. 1994)
The Motor Unit
Motor Unit FunctionMotor Unit FunctionFUNCTION SLOW MOTOR UNITS
(tonic)FAST MOTOR UNITS
(phasic)
Load Threshold easily activated requires higher stimulus
Recruitment primarily recruited at low %of MVC (< 25%)
increasingly recruited athigher % of MVC (40+ %)
Role fine control of posturalactivity & low load activity
rapid or ballistic movement& high load activity
Muscle SpindleMuscle Spindle
Afferent feedback for motor control
Regulation of muscle stiffness
Gamma system strongly influences recruitment of SMU
Local Stability MusclesLocal Stability MusclesFunction
muscle stiffness to control segmental translation
no or minimal length change in function movements
anticipatory recruitment prior to functional loading provides protective stiffness
activity is continuous and independent of the direction of movement
(review: Comerford & Mottram 2001)
Global Stability MusclesGlobal Stability MusclesFunction
generates force to control / limit range of movement
functional ability to (i) shorten through the full inner range of joint motion (ii) isometrically hold position (iii) eccentrically control the return
low threshold eccentric deceleration of movement (rotation)
activity is non-continuous and is direction dependent
Primal Pictures
(review: Comerford & Mottram 2001)
Global Mobility MusclesGlobal Mobility MusclesFunction
generates force to produce range of movement
concentric acceleration of movement ( sagittal plane: power)
High load shock absorption activity is especially phasic
(on:off pattern) and is direction dependent
Primal Pictures
(review: Comerford & Mottram 2001)
Local stability segmental Local stability segmental controlcontrol
The segmental stability of the spine is dependent on recruitment of the deep local stability muscles
The spine will fail if local activity is insufficient even if the global muscles work strongly
1 –3 % MVC muscle stiffness significantly increases stability
25% MVC = optimal stiffness & stability(Cholewicki & McGill 1996, Crisco & Panjabi 1991,
Hoffer & Andreasson 1981)
Local Muscle System Local Muscle System DysfunctionDysfunction
There are changes in motor recruitmentresulting in a loss of segmental control
local inhibition
Dysfunction inDysfunction in Local Stability SystemLocal Stability System
Motor control deficit associated with delayed timing or recruitment deficiency
(Hodges & Richardson 1996)
Reacts to pain & pathology with inhibition(Stokes & Young 1984, Hides et al. 1994)
Decrease in muscle stiffness and poor segmental control
Loss of control of joint neutral position
Vastus Medialis ObliqueVastus Medialis Oblique
60 ml knee effusion significantly inhibits all of the quadriceps
40 ml effusion (sub clinical) inhibits VMO selectively
(Stokes & Young 1984)
Transversus AbdominisTransversus Abdominis Activates prior to movement of
the limbs or trunk to stiffness and stability of the spine
Its activity is independent of the direction of trunk movement or limb load
(Cresswell 1992, 1994)
(Hodges and Richardson 1995, 1996)
Transversus AbdominisTransversus Abdominis A motor control deficit is present
in subjects with low back pain
Activation of transversus is significantly delayed
The timing delay is independent of the type or nature of pathology
(Hodges & Richardson 1995 1996)
Transversus AbdominisTransversus Abdominis
AD
TrA
IO
EO
RA
MF
-0.2 -0.1 0 0.1Time (s)
PD
TrA
IO
EO
RA
MF
-0.2 -0.1 0 0.1Time (s)
MD
TrA
IO
EO
RA
MF
-0.2 -0.1 0 0.1Time (s)
Flexion Abduction Extension
NLBP
(Hodges & Richardson 1996 Spine 21: 2640-2650)
Transversus AbdominisTransversus Abdominis
-0.2 -0.1 0 0.1Time (s)
AD
TrA
IO
EO
RA
MF
-0.2 -0.1 0 0.1Time (s)
MD
TrA
IO
EO
RA
MF
-0.2 -0.1 0 0.1Time (s)
Flexion Abduction Extension
PD
TrA
IO
EO
RA
MF
(Hodges & Richardson 1996 Spine 21: 2640-2650)
LBP
Lumbar MultifidusLumbar Multifidusasymmetry of cross
sectional area of multifidus in back pain subjects
(Stokes et al. 1992)(Hides et al. 1994, 1995)
( Richardson et al. 1998, Hides et al. 1995, 1996)
dysfunction does not correct automatically when pain resolves & specific training can correct dysfunction and recurrence
Dysfunction inDysfunction inGlobal Mobility SystemGlobal Mobility System
Myofascial shortening which limits physiological and / or accessory motion
Overactive low load or low threshold recruitment
Reacts to pain and pathology with spasm
DYSFUNCTION:DYSFUNCTION:What comes 1What comes 1stst ? ?
Global dysfunction can precede and contribute to the development of pain & pathology
Pain & pathology are not a necessary consequence of global dysfunction
Local dysfunction does not precede the development of pain and pathology but rather is due to pain & pathology
Pain & pathology do not have to be present (may be related to distant history)
‘‘Motor Control’ Stability Motor Control’ Stability versus versus
‘Core’ Stability‘Core’ StabilityMotor control stability
= low threshold recruitment of local and global stability muscle system
– Well supported by the research literature
Core stability = high threshold recruitment of proximal trunk &
girdle muscles
Multifidus Muscle Recovery Is Multifidus Muscle Recovery Is Not Automatic After Acute Not Automatic After Acute
First Episode LBP First Episode LBP Hides, Richardson, Jull. SPINE 1996:21Control(n=19) medical management/
activitySpecific ex.(n=20) +med manage/ activityMultifidus ex. 2x/wk x 4 weeksUltrasound image: smaller multifidus on
painful side in all at start
ResultsResults
Multifidus CSA at most affected vertebral level painful side difference corrected in ex group but not in controls at 4 and 10 weeks.
P<0.0001 at both timesPain and Disability scores same in groups
(pain and disability resolved at 4 wks in 90%)
Long Term Effects of Long Term Effects of Stabilizing Exercises for First-Stabilizing Exercises for First-
Episode LBPEpisode LBPHides, Jull, Richardson. SPINE 2001:26Control(n=19) medical management/
activitySpecific Ex(n=20) +med manage/ activity Multifidus ex. 2x/wk for 4 weeks
ResultsResults
1 year recurrence: control=84%, ex.=30%P<0.0013 year recurrence: control=75%, ex.=35%P<0.01 (3 controls lost at 3 year)
Therapeutic Exercise for Therapeutic Exercise for Spinal Segmental Stabilization Spinal Segmental Stabilization
in LBPin LBPScientific Basis and Clinical ApproachRichardson, Jull, Hodges, and HidesChurchill Livingstone 1999
Cervical muscle dysfunctionCervical muscle dysfunction
RCPMaj & RCPMin show atrophy and fatty degeneration in chronic neck pain
(Hallgren et al 1994, McPartland et al 1997)
Anterior neck muscles show slow fast fiber transformation in chronic neck pain
(Uhlig et al 1995)
Noxious meningeal stimulation neck and jaw EMG activity
(Hu et al 1995)
Deep cervical flexor Deep cervical flexor dysfunctiondysfunction
Pressure biofeedback: incremental lordosis flattening pressure during active upper cervical flexion
EMG: activity in anterior neck mobiliser muscles
• (Jull 1994)
Deep cervical flexor Deep cervical flexor dysfunctiondysfunction
Control Can control greater
range of 2mm Hg increments (up to 28 from baseline of 20) than WAD
Less superficial muscle activity
WAD Can only control low
increments (from baseline of 20 up to 23)
Less consistent duration of hold
More superficial muscle activity
Jull 2000
Deep cervical flexor Deep cervical flexor dysfunctiondysfunction
identified in different pathological situations– Whiplash Associated Disorder (Jull 2000)
– Post-concussional headache (Treleaven et al 1994)
– Cervical headache (Watson & Trott 1993,Jull et al 1999)
– Mechanical neck pain (Silverman et al 1991, White & Sahrmann 1994, Jull 1998)
A Randomized Controlled A Randomized Controlled Trial of Exercise and Trial of Exercise and
Manipulative Therapy for Manipulative Therapy for Cervicogenic Headache Cervicogenic Headache
Jull, Trott, Potter, et. al.SPINE: Vol. 27, No. 17, pp. 1835-1843
Inclusion CriteriaInclusion Criteria
1 + HA/week for 2mo. – 10 yrCervicogenic headache (not MT or
Migraine)
MethodsMethods
Randomized: Control, Manual Therapy (Maitland), Exercise (motor control), or Exercise and Manual Therapy
6 weeks of treatment (8-12 visits)Outcome Measures: 7weeks, 3,6, and 12mo.Change in HA frequency (intensity and
duration were secondary measures)Physical assessments
Results: % of Subjects with Results: % of Subjects with 50% and 100% Dec. in HA 50% and 100% Dec. in HA
Frequency – Week 7Frequency – Week 7 50% 100%MT+Ex 81% 42MT 71 33Ex 76 31Control 29 04
The meaning of Life ?The meaning of Life ?
The control of stability The control of stability dysfunction !dysfunction !