Exercise Management of the Spine Patient Presented by

Exercise Management of the Spine Patient Presented by Traci Schafer, PT MPT, cert MDT, CMP

I have no financial disclosures

Objectives • Discuss role of active Physical Therapy in the treatment of common spine diagnoses • Discuss importance of posture for ongoing management • Discuss importance of regular corrective exercise for ongoing management

Role of Physical Therapy • Evaluate and treat impairments that interfere with patients ability to perform daily occupational and/or recreational activities. Common impairments relating to spine diagnoses include: Facet hypomobility, Internal Disc Displacement, Radicular Symptoms, Myofascial pain, ROM loss, Muscle Tightness and adherent nerve root. • Research concludes that regular mechanical loading of joints and or tissues (i. e exercise!) is the most effective modality to decrease pain and prevent recurrence of pain.

Role of Posture • Most injuries to the spine are reported in PT as occurring for “no apparent reason. ” In reality, the injury is an effect of repetitive prolonged poor static postures or repetitive dynamic postures performed incorrectly. The result is an accumulation of postural stresses on the spine and supporting structures. • Standing desks are becoming more popular to improve circulation, improve mood and productivity in the workplace

Effects of Slouched Sitting • Lower cervical flexion/protrusion • Upper cervical extension • mid range flexion of upper thoracic and lower lumbar spine • End range flexion of low thoracic and mid lumbar spine • Posterior pelvic tilt • End result: Excessive spinal flexion

Posture Correction Good Posture Poor Posture

Most Common Corrective Exercise for Cervical Spine: Retraction • Retraction: o Upper cervical end range flexion o Mid cervical mid range extension o Necessary to effectively treat the cervical spine

Retraction

Most Common Corrective Exercise for Thoracic Spine: Extension

Most Common Corrective Exercise for Lumbar Spine: Extension

Common Cervical Stretches • Levator scapula (headaches and neck pain) • O: TP’s of C 1 -4 • I: Superior Medial Scapular Border • Action: Scapular elev, RET, ROT; cervical ipsi SB and ROT; cervical ext

Common Cervical Stretches • Upper trapezius (headaches and neck pain) • O: EOP, medial 1/3 superior nuchal line, ligamentum nuchae and SP of C 7 • I: Posterior border of lateral 1/3 of clavicle • Action on c spine: capital contra ROT; cervical ext

Common Lumbar Stretches • Piriformis (Sciatica, Adherent Nerve Root) • O: Sacrum, ilium near posterior PSIS, SIJ capsule, Sacrotuberous ligament • I: Greater Trochanter of Femur, superior border • Action: Hip ER, assists in abd with flexed hip

Common Lumbar Stretches • Psoas Major (Sciatica, Lumbago) • O: L 1 -5 inferior border of tp’s; T 12 -L 5 vertebral bodies and IVD’s via 5 digitations • I: Lesser trochanter of femur • Action: hip flexion/ER; lumbar SB, flexion

Role of Core Strengthening in Preventive Care • Encourage: activities that focus on both flexion and extension (Yoga); strengthening from the inside, out (Pilates); core strengthening that focus on maintaining more neutral alignment on static and dynamic surfaces (plank/side plank on floor or swiss ball/BOSU) • Avoid: abdominal crunches, dead lifts, weighted trunk rotation, long sitting (all of which compress the lumbar spine); Cross Fit unless you have keen body awareness and know your limitations

Multifidus Training • Lumbar Multifidus • O: L 1 -5 Mamillary process • I: Deep fibers between contiguous vertebra; middle fibers to 2 nd or 3 rd vertebra above; superficial to 3 rd or 4 th vertebra above • Action: Ext, Ipsi SB, Contra ROT

Role of Transverse Abdominis Training • Controversial evidence supporting the role of Tr. A training to “stabilize” the lumbar spine • The ability of intra-abdominal pressure including Tr. A contraction to unload the lumbar spine as a stabilizer forward lifting tasks is low • Definite evidence supporting directional preference movement and centralization vs training the Tr. A to address acute LBP episodes • Definite evidence supporting mind/body conditioning such as Pilates and yoga to address chronic LBP • Recovery of Function, Phase 3 of MDT • Overall physical conditioning and postural awareness with static and dynamic postures more effective than specific Tr. A re-education

Plank & Side Plank

Pilates Reformer

Questions? Thank you! Traci. schafer@utsouthwestern. edu

References • Arjmand, N. , & Shirazi-Adl, A. (2006). Role of intra-abdominal pressure in the unloading and stabilization of the human spine during static lifting tasks. Eur Spine J, 15(8), 1265 -1275. doi: 10. 1007/s 00586 -005 -0012 -9 • Bogduk, N. , Macintosh, J. E. , & Pearcy, M. J. (1992). A universal model of the lumbar back muscles in the upright position. Spine (Phila Pa 1976), 17(8), 897 -913. Retrieved from http: //www. ncbi. nlm. nih. gov/pubmed/1523493 • Calais-Germain, B. (1993). Anatomy of Movement. • Danneels, L. A. , Vanderstraeten, G. G. , Cambier, D. C. , Witvrouw, E. E. , Bourgois, J. , Dankaerts, W. , & De Cuyper, H. J. (2001). Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med, 35(3), 186 -191. Retrieved from http: //www. ncbi. nlm. nih. gov/pubmed/11375879

References, cont. • Do, Y. C. , & Yoo, W. G. (2015). Comparison of the thicknesses of the transversus abdominis and internal abdominal obliques during plank exercises on different support surfaces. J Phys Ther Sci, 27(1), 169 -170. doi: 10. 1589/jpts. 27. 169 • Kim, J. S. , Kang, M. H. , Jang, J. H. , & Oh, J. S. (2015). Comparison of selective electromyographic activity of the superficial lumbar multifidus between prone trunk extension and four-point kneeling arm and leg lift exercises. J Phys Ther Sci, 27(4), 1037 -1039. doi: 10. 1589/jpts. 27. 1037 • Mac. Ewen, B. T. , Mac. Donald, D. J. , & Burr, J. F. (2015). A systematic review of standing and treadmill desks in the workplace. Prev Med, 70, 50 -58. doi: 10. 1016/j. ypmed. 2014. 11. 011

References, cont. • Mc. Kenzie, R. , & Mc. Kenzie, R. (2006). The cervical and thoracic spine: Mechanical diagnosis and therapy vol. 1 (2 nd ed. ). Raumati Beach, N. Z. : Spinal Publications (N. Z. ). • Mc. Kenzie, R. , & May, S. (2003). The lumbar spine: Mechanical diagnosis & therapy (2 nd ed. , Vol. 1). Waikanae: Spinal. • Mc. Kenzie, R. , & Kubey, C. (2000). 7 steps to a pain-free life: How to rapidly relieve back and neck pain using the Mc. Kenzie method. New York: Dutton • Rydeard, R. , Leger, A. , & Smith, D. (2006). Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. J Orthop Sports Phys Ther, 36(7), 472 -484. doi: 10. 2519/jospt. 2006. 2144