for physiotherapist specialy

1. Thoracic and
Lumbar Spine
Injuries
PRESENTED BY:- NISHANK VERMA
SHUBHAM GUPTA
1

2.  Back injuries in the young athlete are a significant phenomenon,
estimated to occur in 10% to 15% of participants. The prevalence,
however, varies between sports and, in some cases, the specialty
position played.
 In gymnastics, the incidence of back injuries is thought to be 11%,
whereas in football linemen, it has been recorded as high as 50%.
2

3.  Back injuries include single-episode macrotrauma ("acute") and
repetitive microtrauma ("overuse") injuries. Efforts have been
successful in minimizing catastrophic acute spinal injuries in contact
sports, such as football, hockey, and rugby, through rule changes
and equipment modification.
 Noakes et al. recently reported a 46% reduction in the number of
spinal cord injuries with the avoidance of the high tackle in
schoolboy rugby, in South Africa.
 On the other hand, the less dramatic, overuse injuries appear to be
increasing as more young athletes are required to perform repetitive
skills as part of their training programs. What is of concern is that
these overuse back injuries, once present, are difficult to overcome,
and recur in 26% of males and 33% of females.
3

4. Low Back Pain in Athletes
 Low back pain (LBP) is an extremely common
symptom in the general population and among
athletes.
 Athletes are at greater risk of sustaining a lumber
(lower) spine injury due to physical activity.
 Whether the sport is skiing, basketball, football, ice
skating, soccer, running, golf, or tennis, the spine
undergoes a lot of stress, absorption of pressure,
twisting, turning, and even bodily impact.
 This strenuous activity puts a strain on the back that
can cause injury to even the finest and most fit
athletes.
4

5. Very Important Talk!! – LBP
 A major public health problem
 The leading cause of disability for people < 45
 2nd leading cause for physician visits
 3rd most common cause for surgical procedures
 5th most common reason for hospitalizations
 Lifetime prevalence: 49%–80%
5

6. Incidence of Low Back Pain
 Mechanical LBP is very common, affecting between 70 and 85% of
American adults at some point during their lives.
 In 90% of patients, LBP resolves within 6 weeks (self limited). In
another 5% of patients, the pain resolves by 12 weeks after initiation.
 Less than 1% of back pain is due to "serious" spinal disease (e.g.,
tumor, infection). Less than 1% of back pain stems from
inflammatory disease (rheumatologic work-up and treatment
required). Less than 5% of back pain is true nerve root pain.
6

7.  Most patients with LBP have one or more of four symptoms:
1. Back pain.
2. Leg pain.
3. Neurologic symptoms.
4. Spinal deformity.
 Jensen and coworkers (1994) found that 64% of asymptomatic
individualswho underwent an MRI had "abnormal” appearing
lumbar discs at some level.
7

8.  Almost all of us (70 to 85%) will develop LBP at some point. For this
reason, it is inappropriate for physicians to tell patients that LBP
results from being obese, inactive, or other factors.
 Workplace and social factors were by far the most powerful
influences on chronicity (84% accurate in predicting who will be
chronically disabled). These were more predictive than type of
injury, health behavior, or other factors.
8

9. Back injuries involving lost work
11%
7%
12%
70%
Lumbar
Thoracic
Cervical
Unspecified
The majority of
back injuries
that result in lost
work time
involve the
lumbar region.

10. Risk Factors for Chronicity of Low
Back Pain
 Previous history of LBP
 Significant work loss (due to LBP) in past year
 low job satisfaction
 Adversarial medicolegal proceedings
 Radiating leg pain
 Reduced SLR (positive test)
 Signs of nerve root involvement
 Decrease performance of athlete
10

11.  Reduced trunk muscle strength and endurance
 Poor physical fitness
 Self-rated poor health
 Heavy smoking
 Psychological distress and depressive symptoms
 Disproportionate illness behavior
 Personal problems-alcohol, marital, financial.
11

12. Risk factors associated with Low
Back Pain
Risk factor Evidence
Age Increased risk until age 50, then
relative risk decreases in men but
increase in women
Gender Multiparous women: three times
risk
Obesity Unclear
Height Unclear
Posture No association with lordosis and
Leg Length Discrepancy
Smoking Strong association with LBP and
sciatica
12

13. Risk factor Evidence
Physical work Increased risk in those whose work involves bending,
twisting or heavy physical labor
Increased risk of LBP and sciatica with exposure to
vibration
Coal miners have fewer disk protrusions than other
occupations
Low risk of LBP in farmers
Sedentary occupation Increased risk when seated
Driving a motor car may cause LBP or herniated disc
Job involving all standing or all sitting show higher
incidence of LBP than those with changing position
Increased fitness Some evidence that good isometric endurance of
back muscles may be associated with reduced LBP
Psychological factors Stress, anxiety, depression associated with work-related
LBP.
13

14. Lumbar Spine Pain Generators
 Nucleus pulposus
 Anulus fibrosis
 Facet joints
 Ligaments
 Muscles
 Nerve
 Synovium
14

15. Causes of Low Back Pain
 Common
 Non osseous injury
Intervertebral disc
Apophysecal joint
 Spondylolysis
 SIJ injury or inflammation
 Paravertebral and gluteal muscle trigger
points
 Hip joint pathology
15

16.  Less Common
 Intervertebral disc prolapse
 Spondylolisthesis
 Lumbar instability
 Spinal canal stenosis
 Vertebral crush fracture
 Fibromyalgia
 Rheumatological
 Gynecological
 Gastrointestinal
 Genitourinary
16

17.  Not to be missed
 Malignancy
Primary
Metastatic
 Osteoid osteoma
 Multiple myeloma
 Severe osteoporosis
17

18. Evaluation of Patients with Low
Back Pain
 A through history and examination allows an accurate working
diagnosis to be made in 90% of patients with LBP.
 General History (Demographic Information)
 History of Present Illness
 Medical History
 Family History
 Social History
18

19. Physical examination of lower back
 Observation and palpation
 Gait
 Range of motion of lower back and hip joints
 Hip FABER examination
 Muscle Strength
 Tendon Reflexes, Pathologic Reflexes
 Sensory Testing
19

20. 20

21. Nerve Tension Tests
 Straight Leg Raises Test (PSLRT)
 Lasegue rest
 Crossed SLR test
 Bowstring sign
 Slump test
 Femoral nerve stretch test.
21

22. Common Pathoanatomical Conditions of the Lumbar Spine
22

23. Mechanisms of Injury
 Congenital abnormalities
 Poor body mechanics
 Back trauma
23

24. Intervertebral Disc Pressure 24

25. Classify patient
 Determine cause of problem
 Postural
 Inflammation of soft tissues
 Dysfunctional
 Adaptive Shortening
 Strain or Sprain
 Derangement
 Disk
 Facet joint
 Stress Fracture
25

26. Sprain/Strain Dysfunction/
Postural
Derangement
ONSET Sudden,
simple move
Gradual Sudden,
simple move
PAIN Severe ache,
diffuse, spasm
Ache,
intermittent
Sharp,
burning,
Localized or
Radiating
MOBILITY Reduced,
movement
increases pain
Reduced
mobility of
joint and
stiffness
Guarded
flexion,
extension
decreases
pain
GOALS OF
TX
Decrease pain
Decrease
spasm
Restore ROM
Decrease pain
Increase ROM
Posture
Strength/Flex
Decrease pain
Centralize disc
Prevention
Guide to Lumbar Spine Conditions
26

27. Lumbar Spine Conditions
 Low Back Muscle Strain
 Acute (Overextension) and Chronic (Faulty posture)
 Facet Joint Dysfunction
 Dislocation or Subluxation (Acute or Chronic)
 Low Back fracture
 Compression, Stress, or Spinous and Transverse
Processes
 Herniated Disc
 Protrusion, Prolapse, Extrusion, and Sequestration
 Local and Radiating Pain
 Classic term “Sciatica”
27

28. Lumbar Spine Conditions
 Spondylolysis
 Unilateral defect in the pars interarticularis
 Spondylolisthesis
 Bilateral defect in the pars interarticularis which causes forward
displacement of vertebra.
 Spina Bifida Occulta
 Congenital condition – spinal cord is exposed = delays in development.
28

29. Sacroiliac Joint Conditions
 Sacral torsion
 Forward or Backward torsion
 Ilium torsion, upslip, downslip, outflare, inflare
 Piriformis strain/trigger points
29

30. Diagnosing LBA
 The most common cause of low back pain is when one or more
muscles “forget” to relax. We call this a somatic dysfunction.
 In somatic dysfunction, some muscles become overactive
(“spasm”) and other muscles become inactive.
30

31. Ankylosing spondylitis
 Ankylosing spondylitis is one of many forms of inflammatory arthritis,
the most common of which is rheumatoid arthritis. Ankylosing
spondylitis primarily causes inflammation of the joints between the
vertebrae of your spine and the joints between your spine and pelvis
(sacroiliac joints).
31

32. Unique risk factors for athletes
 High impact trauma:
 football, rugby
 End range loading:
 gymnastics, diving
 Overuse trauma:
 impact loading: distance running
 rotational loading: golf, baseball
 prolonged sitting: travel
32

33. Assessing the Low Back
 On-Field Assessment
 PrimarySurvey
 ABCs
 Level of consciousness/Movement
 Neurological system intact?
 Secondary Survey
 Pain, Dermatomes, Myotomes
 ROM – only if no motor or sensory decrements
 Further assessment on sidelines
33

34. Assessing the Low Back
 Off-Field Assessment
 HISTORY!!!!
 Observation and Palpation
 The Triad of Assessment
 Asymmetry, ROM alteration, Tissue texture
 Special Tests
 Begin to be selective in you choices.
 Classify tests as to their main findings
 Use results of key tests to determine further testing
34

35. Kinetic Chain
 Why do we need to assess the pelvis, hip and lower extremity?
35

36. Foot conditions
 Over-pronation
 Hip flexion
 Anterior pelvic tilt
 Pelvic rotation/Tilt
 Over-supination
 Hip extension
 Hip external rotation
 Pelvic rotation/tilt
36

37. Back Malalignments 37

38. Differential Diagnosis of Low Back
Pain
38

39. I
M
A
G
I
N
G
39

40. X-ray, Anteroposterior View
1. 1st Lumbar vertebra
2. 2nd Lumbar vertebra
3. 3rd Lumbar vertebra
4. 4th Lumbar vertebra
5. 5th Lumbar vertebra
6. T12
7. Twelfth rib
8. Sacroiliac joint
9. Sacrum
10. Sacral foramen
11. Ilium
12. Pelvic brim
13.Superior ramus of
pubic bone
14. Pubic symphysis
40

41. 1. Vertebral body
2. Spinal cord
3. Conus medullaris
4. Intervertebral disc
5. Filum terminale
(internum)
6. Subarachnoid
space
Lower Third of Spinal Cord, MRI 41

42. Sagittal Section through the Spinal
Cord
1. Intervertebral disc
2. Vertebral body
3. Dura mater
4. Extradural or epidural
space
5. Spinal cord
6. Subarachnoid space
42

43. MANAGEMENT
 Non-specific low back pain
 NSAIDs and muscle relaxants good for symptomatic relief
 Spinal manipulation of limited utility in studies
 Should recommend rapid return to normal activities with neither bed
rest nor exercise in the acute period
 Bed rest found to not improve and may delay recovery
 Exercises not useful in acute phase; use in chronic ( according to
patient response)
 Traction, facet joint injections, TENS ineffective or minimallyeffective
 Systematic reviews of acupunture have shown little benefit
 Massage therapy  some promising results
 Surgery only effective for sciatica, spinal stenosis or spondylolisthesis
43

44.  Chronic low back pain
 Intensive exercise improves function and reduces pain
 Anti-depressants: many with chronic low back pain are also depressed
 Maybe for those without depression (tricyclics)
 Opiates
 showed better effect on pain and mood than NSAIDs
 No improvement in activity
 Significant side effects: drowsiness, constipation, nausea
 Referral to multidisciplinary pain center
 Cognitive-behavioural therapy, education, exercises
 Surgical procedures rarely helpful
44

45. 45

46. Bed rest Recommendations for the Treatment of Low
Back Pain
Royal College of General Practice Guidelines
Conclusions
 For acute or recurrent LBP with or without referred leg pain, bedrest for 2-7 days
is worse than placebo or ordinary activity. It is not as effective as the alternative
treatments to which it has been compared for relief of pain, rate of recovery,
return to daily activities,and days lost from work.
 Prolonged bedrest may lead to debilitation, chronic disability, and increasing
difficultyin rehabilitation.
 Advice to continue ordinary activity can give equivalent or faster
symptomatic recovery from the acute attack, and lead to less chronic disability
and less time off work than "traditional" medical treatment With analgesics as
required, adviceto rest, and let pain be your guide for return to normal activity.
 Graded reactivation over a short period of days or a few weeks, combined with
behavioral management of pain, makes little difference to the rate of initial
recovery of pain and disability,but leads to less chronic disabilityand work loss.
 Advice to return to normal work within a planned short time may lead to shorter
periods of work loss and less timeoff work.
46

47. Recommendations
 Do not recommend or use bedrest as a treatment for simple back
pain.
 Some patients may be confined to bed for a few days as a
consequence of their pain but this should not be considered a
treatment.
 Advise patients to stay as active as possible and to continue normal
daily activities.
 Advise patients to increase their physical activities progressively over
a few days or weeks.
 If a patient is working, then advice to stay at work or return to work
as soon as possible is probably beneficial.
47

48. Physical Therapy Approaches in
Low Back Pain:-
 In patients with LBP and concomitant radiating leg pain, McKenzie
(1981) has described a clinical phenomenon known as
"centralization“.
 During McKenzie's procedure, a change in pain location from
peripheral (or distal) to a more proximal (or central) location is
desired during the mechanical assessment and manipulative
evaluation.
 Determination of the initial movement pattern to be used by the
therapist is based on presumed pathology (e.g., discogenic versus
posterior element pain), pain pat tern, and successful pain
centralization.
48

49. Extension Bias
 As a very generalized guideline, the extension bias is most
commonly used with Discogenic pathology; symptoms decrease
with repetitive extension on motion pattern testing and pain
centralizes with extension.
 Extension exercises may reduce intradiscal pressure, allowing
anterior migration of the nucleus pulposus away from the area of
pathologic compression.
 Extension exercises may actually increase symptoms in patients with
large central disc herniation, foraminal stenosis, or foraminal
herniation.
49

50.  Cardiovascular fitness may then be initiated with an exercise that
employs a neutral to extension bias in these patients to avoid
aggravation of the patient's back pain during aerobic exercise
(e.g., use of aquatic stabilization training or cross-country ski
machine).
50

51. Flexion Bias
 Flexion bias is most commonly used in patients with posterior spine
element (e.g., facet) pain. In these patients, symptoms decrease with
repetitive flexion on motion pat tern testing and pain centralizes with
flexion.
 Flexion exercises (see later) may act to reduce facet joint compression
and provide stretch to lumbar musculature, ligaments, and myofascial
structures.
 Flexion actually increases intradiscal pressure and ex acerbates
discogenic symptoms.
 Cardiovascular exercises in patients with posterior spine element pain
may be initiated with stationary bicycling in slight lumbar flexion or
aquatic stabilization exercises in slight lumbar flexion. These activities
place the spine in a neutral to flexion bias.
51

52. Exercise Programs for Low Back
Pain
 Several exercise programs have been developed for acute LBP.
 These include those designed by McKenzie (mainly extension
exercises) (1981), Williams (1937), Aston (1999), Heller (1991), and
Feldenkrais (Lake 1985), and other lumbar stabilization programs,
stretching regimens, and aerobic conditioning programs.
52

53. McKenzie Technique
 Treatment is based on evaluation of pain location and maneuvers
that change the pain location from referred to centralized.
 McKenzie recommends implementation of this protocol by a
therapist with specialized training in the McKenzie method to ensure
proper recognition and correct implementation of treatment in
response to the patient's clinical relief derived from specific
maneuvers. To determine which exercises produce centralization,
the physical therapist tests the patient with a standardized series of
lumbar movements, such as flexion, extension, lateral bending,
rotation, and side-gliding (a combination of lateral bending and
rotation).
53

54.  Once the therapist identifies the movement (usually extension or
lateral bending) that decreases peripheral symptoms, the patient is
taught to perform an individualized exercise program in that
direction of movement.
 The movement is performed repetitively to the passive end-range.
Maneuvers that "peripheralize" or exacerbate symptoms are
discontinued.
 This technique is best for Acute Low Back Pain.
54

55. 55

56. Repeat End-Range Movements
While Standing
 Back-bending (extension)
 Side-gliding
 Forward-bending (lumbar flexion)
56

57. 57

58. Recumbent End-Range
Movements
 Passive extension while prone
 Knees-to-chest while supine
 Prone lateral shifting of hips off midline (patients with unilateral
symptoms)
 Flexion while sitting
58

59. 59

60. 60

61. Williams Flexion Exercises
 The goals of this isometric flexion regimen, developed in the 1930s,
are to
 (1) widen the intervertebral foramina and facet joint to reduce
nerve compression,
 (2) stretch hip flexors and back extensors,
 (3) strengthen abdominal and gluteal muscles, and
 (4) reduce "posterior fixation" of the lumbosacral junction.
61

62.  A concern with this method is that certain flexion maneuvers
increase intradiscal pressure, possibly aggravating herniated or
bulging discs. According to Nachemson (1981), Williams' first
exercise increases intradiscal pressure to 210% over that in a
standing posture. Three of the six exercises increase intradiscal
pressure, and these three are contraindicated for patients with
acute herniated disc.
62

63. 63

64. Lumbar Stabilization Programs
 Practitioners with backgrounds in martial arts or sports training and
some therapists with European influences in training developed
stabilization training primarily for these patients.
 The main goal of the lumbar stabilization program is to build
musculature that stabilizes the torso, with cocontraction of
abdominal muscles to provide a corseting effect on the lumbar
spine.
 This concept is centered on the assumption that an injured lumbar
motion segment may create a weak link in the kinetic chain, with
subsequent predisposition to reinjury.
64

65. Exercise Training in the Lumbar
Stabilization Program
 Soft tissue flexibility
 Hamstring musculotendinous unit.
 Quadriceps musculotendinous unit.
 Iliopsoas musculotendinous unit.
 Gastrocnemius-soleus musculotendinous unit.
 External and internal hip rotators.
65

66.  Joint mobility
 Lumbar spine segmental mobility
Extension
Flexion (unloaded)
 Hip range of motion.
 Thoracic segmental mobility.
 Stabilization Program
 Finding neutral position
 Standing
 Sitting
 Jumping
 Prone
66

67.  Prone gluteal squeezes
 With arm raises
 With alternate arm raises
 With leg raises
 With alternate leg raises
 With arm and leg raises
 With alternate arm and leg raises
 Supine pelvic bracing
 Bridging progression
 Basic position
 One leg raised with ankle weights
 Stepping
 Balance on gym ball.
67

68.  Quadruped
 With alternate arm and leg
movements.
 Kneeling stabilization
 Double knee
 Single knee
 Lunges, with and without weight
 Wall slide quadriceps
strengthening
 Position transition with postural
control
 Abdominal program
 Curl-ups
 Dead-bug, supported &
unsupported
 Diagonal curl-ups
 Diagonal curl-ups on incline board
 Straight-leg lowering
68

69.  Gym program
 Latissimus pull-downs
 Angled-leg press
 Lunges
 Hyperextension bench
 General upper body weight
exercises
 Aerobic program
 Progressive walking
 Swimming
 Stationary bicycling
 Cross-country ski machine
 Running- initially supervised on a
treadmill.
69

70. THE CORE
 Low back and abdominal exercises are prescribed primarily for
 rehabilitation of injured low back
 Prevention of injury
 As a component of fitness training programs
 Goal is to stress both damaged and healthy supporting tissue to
promote tissue repair
 while avoiding further excessive loading that can exacerbate existing
structural weakness
 ACSM chapter discusses the science of understanding loading forces and
revisits some common practices in abdominal and low back training
 Most effective
 train motor control system to activate spine stabilizers
 Progress to endurance training
 Finally enhance strength and flexibility
70

71. 71Core Stability
 Stabilizing muscles - act to support muscle action by
providing rigid base of support for movement
 Core stability provided by muscles in the torso
connecting the spine, rib cage and pelvis
 When standing the pelvis and lumbar spine are
oriented for maximal stability
 Goal of training is to maintain this “neutral spine”
orientation throughout dynamic movement
 Lumbosacral angle ~ 41 degrees
 Stabilizing exercise are ones that groove motor
patterns and ensure a stable spine during activity

72. 72Assessment
 Muscular endurance closely related to spinal stability and risk of
low back pain
 Balance of muscular endurance among torso flexors, extensors and
lateral musculature is most important in reducing injury risk
 All tests evaluated on time to failure and compared to normative
data for overall time and ratios between test scores
 Lateral musculature test
 Test performed on both sides of the body
 Lying in full side bridge, legs extended, top foot in front
 subject supported on one elbow and feet while lifting hips off the
floor to create a straight line over their body length
 Uninvolved arm placed across the chest with hand on opposite
shoulder
 Failure occurs when person loses the straight-back posture and hip
returns to ground

73. 73

74. 74Assessment
 Flexor endurance test
 Begins with person in a sit-up posture with the back
resting against a jig angled at 60 degrees
 Knees and hips flexed at 90 degrees
 Arms folded across chest
 Hands on opposite shoulders
 Toes are secured by examiner or toe straps
 Test begins by pulling support back ten centimeters
 Failure occurs when subject falls back and touches jig

75. 75

76. 76Assessment
 Back extensors test
 Upper body cantilevered over the end of test bench -
hands across chest
 Time to failure - drop from horizontal

77. 77

78. 78Core Exercise Training
 Focus on progressive
exercise that emphasizes
muscle contraction with
the spine in neutral
position
 Spine posture determines
interplay between
ligament and muscle
forces
 Extensor muscles
activated in neutral
position reducing load on
spine
 Fully flexed spine fails at
about 20-40% lower
compressive load than
with neutral position

79. The line of gravity
shifts further ventrally
during relaxed
unsupported sitting
(B) as the pelvis is
tilted backward and
the lumbar lordosis
flattens (this creates
a longer lever arm).
When sitting erect
(C) the pelvic
backward tilt is
reduced and the
lever arm shortens
(still longer than
when standing (A).
79

80. 80Exercise Training
 Several exercises are required to train all of the
muscles of the lumbar torso
 Individual fitness level, training goals, history of spinal
injury should influence prescription
 Exercises should avoid loading spine throughout
ROM post injury
 Elite athletes may achieve higher performance
levels by using full ROM in exercises

81. 81Abdominal Bracing and Neutral Spine
 Teaching Abdominal bracing
 co-contraction of abdominal wall muscles for spinal
stability
 1. Demonstrate joint stability in peripheral joint
through flexor/extensor co-contraction
 have subject palpate demonstrator then themselves
 2. Identify core musculature - cough with hand
above hips - palpate abdominal wall during
contraction

82. 82Abdominal Bracing and Neutral Spine
 Teaching Neutral spine
 1. lying on back, knees bent - place fingers between
lumbar spine and floor
 hyper lordosis - increase gap from floor
 hypo lordosis - flatten back onto fingers
 Can utilize blood pressure cuff and observe rise and fall in
pressure with same movements.
 2. Put subject through lifting exercise or simulated work
situations
 Place long stick across lumbar, subject must maintain contact
across lumbar, avoiding trunk flexion throughout motion.

83. 83

84. 84Core Exercises
 All endurance exercises should last up to seven to
eight seconds
 Progression in program should come from adding
more repetitions rather than adding duration
 Utilize normative data from assessments to develop
client goals
 Curl ups reduce spinal compression compared to sit
ups and leg raises
 Press heel sit-ups - recent evidence advanced them as
beneficial
 However, active hamstrings actually stimulate psoas
activity and higher compressive penalty on spine

85. 85
Abdominal Exercises
 Partial Curl ups
 Focus on rectus abdominus
 Distinct upper and lower rectus abdominus do not exist in most
people
 training can be accomplished with a single exercise
 Retain neutral spine, do not flatten back to floor
 Beginner
 Supine with hands supporting lumbar spine
 One leg bent at 90 degrees
 Lift thoracic and cervical spine as one unit, no cervical motion
should occur (chin poking or chin tucking)
 Leave elbows on floor, contract rectus and lift head and shoulders
off the floor
 Intermediate
 lift elbows slightly off floor
 Advanced
 place fingers lightly on forehead
 Head and neck must move as unit, maintaining rigid block position
on thoracic spine

86. 86
Abdominal Exercises
 Horizontal Side bridge
 Challenge lateral obliques and quadratus lumborum
 Low lumbar compressive load
 Variable demand on rectus and others with progressive stages of
exercise
 Remedial
 Standing 45 degrees and leaning to wall
 Lying on floor and raising legs
 Utilizeback extensionbench at 45 degrees and support from side
 Beginner
 Lateral support on knees bent at 90 degrees and elbow, maintain torso
straight
 Top arm across chest with hand on shoulder
 Intermediate
 Legs straight with top foot in front
 Variation- incorporatelongitudinal rolling of the torso forward and backward
 Advanced
 Transfer from one elbow to the other while maintaining abdominal bracing

87. 87
Extensor exercises
 Traditional extensor exercises - high spinal loads due to ext applied loads from
weights of resistance machines
 bird dog
 Remedial
 Raise a hand or knee slightly off floor
 Beginner
 Singleleg raise on hands and knees
 Intermediate
 Simultaneous contra-lateral arm raise with leg raise - increases extensor challenge
 Hold six to eight seconds when parallel
 Advanced
 Do not rest by placing the hand and knee on the floor after each holding repetition
 Sweep the floor with hand and return out
 Common errors include hiking hips and not achieving neutral spine
 exercise lying prone and lifting legs is contraindicated for anyone at risk for low
back injury due to hyperextension

88. 88

89. 89Advanced exercises
 athletes can incorporate forced breathing cycles into all
exercises
 Labile surfaces - exercise ball, wobble boards
 Increase co-contraction, doubling spinal load in many exercises
 Not recommended until subject has achieved spinal
stability and sufficiently restored load-bearing capacity
 Can delay improvements by causing exacerbating spine loads if
adopted early in rehabilitative program

90. 90

91. 91Advanced exercises
 Ball Exercises
 Table top spine
 Forward ball roll
 Total body flexion
 Curl up
 Push up

92. 92

93. 93

94. 94

95. 95

96. 96

97. 97Advanced exercises
 Squat and Power cleans
 Great for developing power
 Form is more important than weight being lifted as
injury is likely
 Europeans, practice technique for years before adding
weight
 Recommend beginning from elevated position if
not a competitive weight lifter
 McGill recommends athletes use medicine ball in
the same motion pattern to avoid high stress of
lifting bar from ground

98. 98Aerobic exercises
 Evidence supporting positive role of aerobic
exercise in reducing incidence of low back
injury and in the treatment of low back patients
 Walking
 Low levels of support tissue load
 Mild, prolonged activation of supporting musculature
 Study comparing elderly engaged in a variety
of lifelong activities
 Runners - no detrimental changes in low back health
 Weightlifters and soccer players - more disc
degeneration and bulges

99. 99Flexibility
 Flexibility of the spine has yet to be shown to improve
outcomes of low back exercise programs or reduce risk
of future injury in healthy populations
 Flexibility of hip has shown to be important
 Avoiding end of ROM during athletic and daily activities
can reduce risk for several types of injuries
 Limit training to unloaded flexion/extension
 Fig 13.4 cat stretch - full ROM recommended only for
athletes who have never had a back injury
 Hip and knee flexibility should be performed with
neutral spine

100. 100

101. 101
Exercise Prescription
 Recommendations
 Low back exercise most beneficial if performed daily
 No pain, no gain does not apply
 Inclusion of general exercise (aerobic) is most effective
 Unwise to perform full ROM of spine early in the morning - Disc
more hydrated in morning
 Emphasis should be endurance over strength, for low back
health
 Training objectives must be identified individually in terms of
 injury risk, optimizing health or maximizing athletic performance
 May take 3 months to observe increase function and pain
reduction

102. Back
Problem
Weakness
Stiffness
Stop
Moving
Hurts to
Move
Back Injury Cycle 102

103. How do I Take Care of My Back ?
 Body Mechanics
 Proper Lifting Techniques
 Exercise
 Stretching
 Correct Posture
103

104. “It’s not how much you lift or move, but the way you
do it”!
General Rules:
1) Push vs. Pull
2) Keep Work Within “Strike Zone”
3) Keep Load Close To Body
4) Use Abdominal Bracing
5) Pivot with Feet - Avoid Twisting
6) Team Work vs. Mule Work
Body Mechanics
104

105.  Power Position:
 Wide base of support
 Feet shoulder width apart
 Back straight
 Head and shoulders up
 Bend at hips and knees - NOT BACK!
 Keep load close to body
 Tighten stomach muscles
 Use leg, hip and buttock muscles
 Breathe out with lift
Proper Lifting Techniques 105

106. CONDITIONING 106

107.  Increased Strength
 Increased Endurance
 Decreased Risk of Injury
 Better Job Performance
Benefits of Conditioning 107

108. 1. Sit Straight
2. Stretch Out
3. Walk Tall
Correcting Posture 108

109. Posture
Bad posture can be the cause of spinal pain, it can make existing pain
worse, and it certainly can make the pain last a lot longer.
109

110. Piriformis Syndrome
(Pseudosciatica)
110

111.  The Piriformis muscle arises from the anterior
surface of the sacrum and passes
posterolaterally through the sciatic notch to
insert into the upper border of the greater
trochanter.
 The sciatic nerve exits the pelvis through the
sciatic notch and descends immediately in
front of the piriformis muscle.
 In 10% of the population, anatomical
variations result in the sciatic nerve passing
through the piriformis muscle. female–to–
male ratio of 6:1.
111

112.  Piriformis syndrome was first described in 1947 by Robinson as
a ‘‘type of sciatica which is due to an abnormal condition of
the piriformis muscle, usually traumatic in origin.’’
 This particular condition may be considered an entrapment
syndrome.
 Although known as the “piriformis syndrome”, this would be
better referred to as “piriformis impingement”.
112

113. Epidemiology and Risk Factors
 The incidence rate of piriformis syndrome ranges from 0.33% to
6%, with a female-to-male preponderance ranging from 3:1 to
6:1.
 Aside from direct trauma, causative physical activities are
extremes of running, hiking long distances, or climbing.
 Each of these activities requires the athlete to perform
numerous, repetitive hip extension maneuvers (e.g., Eco
Challenge, triathlons, marathons, and speed skating).
113

114. Etiology of the piriformis syndrome
 Gluteal trauma in the sacroiliac or gluteal areas
 Predisposing anatomic variants
 Myofascial trigger points
 Hypertrophy and spasm of the piriformis muscle
 Secondary to laminectomy
 Abcess
 Hematoma
114

115.  Myositis
 Bursitis of the piriformismuscle
 Neoplasms in the area of the infra piriformis foramen
 Colorectal carcinoma
 Neuroma of the sciatic nerve
 Epi sacroiliac lipoma
 Intra gluteal injection
 Femoral nailing
 Myositis ossificans of the piriformis muscle
115

116. Types of piriformis syndrome
 A primary condition that is intrinsic to the piriformis occurs after a
fall in which the individual forcibly strikes the ground while bent
forward or flexed at the torso (e.g., hockey and football players,
gymnasts, and cheerleaders). Primary injury also occurs in a near
fall when the piriformis violently contracts to maintain balance.
 A secondary condition includes piriformis irritation caused by SI
joint dysfunction. Because of the piriformis muscle’s unique
orientation and because it is the only muscle to cross the SI joint,
the piriformis plays a large role in SI joint pain. In addition, any
lesion or dysfunction of the SI joint can release inflammatory
cytokines, which induces a paracrine inflammatory response on
the piriformis muscle and its fascia and predisposes to spasm.
116

117. Clinical Features
 The cardinal features of this syndrome include a history of trauma to
the SI and gluteal regions;
 Regional pain localized to the SI joint, the greater sciatic notch, and
the piriformis muscle that extends down the limb;
 Acute exacerbation of pain by stooping and lifting;
 A palpable tender myofascial point within the involved piriformis
muscle;
 A positive Lasegue sign (straight leg raise) with prolonged hypertonicity
or irritation; and
 Gluteal atrophy as a result of compression of the superior and inferior
gluteal nerve(s).
 The most notable hallmark of this condition is the development of
sciatic neuritis.
117

118. History
 A history of a fall or another related direct trauma to the gluteal
region as well as activities that cause a prolongation o
exacerbation of hip rotation/extension will normally be reported
by the athlete.
 Complaints of buttock pain with or without radiation to the
posterior thigh, knee, and calf are usually present.
 Hip adduction and internal rotation activities increase the
symptoms as a result of the stretch placed on the piriformis.
 Patients may complain of pain while performing either hip
extension and/or flexion as a result of the unique biomechanics
of this muscle. As the hip is flexed, the piriformis contracts, which
aids in the flexion. Likewise, when the hip extends, the piriformis
also contracts, thus assisting with this motion.
118

119.  The key clinical characteristic is the complaint of sitting
intolerance because sitting places direct pressure on the
spasming muscle.
 In addition, because of the proximity of the piriformis to the
lateral pelvic wall, patients may also complain of
dyspareunia or pain with bowel movements, resulting from
the activation of the pelvic splanchnic nerve.
 One major distinction between this condition and other
sciatica-producing conditions (e.g., herniated nucleus
pulposus) is the lack of true radiculopathy in piriformis
syndrome.
119

120. Physical Examination
 Physical examination findings that are indicative of piriformis
syndrome include a palpable tender point within the muscle
belly, origin, or insertion.
 Painful resisted active external rotation of the hip while seated
and in the fully internally rotated position is considered the most
specific test for differentiating this condition from other causes of
pain.
 Patients with a long history of piriformis syndrome may develop
gluteal atrophy as a result of the entrapment of the peritoneal
branch of the sciatic nerve.
 This gluteal atrophy is more commonly found in the elder athlete
with a positive Trendelenburg sign and motor weakness along
the S1 myotome.
120

121.  On examination, there is tenderness either in the belly of the
piriformis or more distally near its insertion into the greater
trochanter.
 Passive internal hip rotation is reduced and resisted abduction with
the hip adducted and flexed may reproduce the pain over the
piriformis.
 Pain may also be reported by resisted external rotation with the hip
and knee flexed, beginning from a position of internal rotation so
that end range is tested.
121

122. Investigations
 As a result of the associated neural involvement with this
condition, all necessary studies should be performed to rule out
spinal causes of sciatica and SI joint or hip pathology.
 Computed tomography (CT) scanning, MRI scanning, and
scintigraphy with technitium- 99m bone scanning rarely
demonstrate any identifiable piriformis abnormality.
 However, neurophysiologic testing has proven helpful. The
peritoneal branch of the sciatic nerve and the internal gluteal
nerve may demonstrate signs of denervation from the
compression of a hypertrophied piriformis.
 Nerve conduction studies will demonstrate delays in the H
reflexes of these nerves.
122

123. Differential Diagnosis
 Dysfunction,lesion and inflammation of sacroiliac joint
 Pseudoaneurysm in the inferior gluteal artery following
gynaecologic surgery
 Thrombosis of the iliac vein
 Painful vascular compression syndrome of the sciatic nerve,
caused by gluteal varicosities
 Herniated intervertebraldisc
 Post-laminectomy syndrome or coccygodinia
 Posterior facet syndrome at L4-5 or L5-S1 Unrecognized pelvic
fractures
 Lumbar osteochondrosis
 Undiagnosed renal stones
 Lumbosacral radiculopathies
123

124.  Osteoarthritis (lumbosacral spine)
 Sacroiliac joint dysfunction
 Degenerative disc disease
 Compression fractures
 Intra-articular pathology in the hip joint: labral tears, femuro-
acetabular impingement (FAI)
 Lumbar spinal stenosis
 Tumors, cysts
 Gynecological conditions
 Diseases such as appendicitis, pyelitis, hypernephroma, uterine
disorders, prostate disorders and malignancies in pelvic
viscera.
 Psychogenic disorders: physical fatigue, depression, frustration
 Sacroiliitis
124

125. Treatment
 Physical therapy has become the main focus for conservative
treatment of patients with piriformis syndrome.
 Focusing treatment on relieving the pain through stretching and
decreasing swelling should lead to decompression of the sciatic
nerve and thus relieve symptoms.
 Due to the anatomical location of the piriformis, lying deep to the
gluteus maximus, moist heat or ultrasound is often used prior to
stretching in order to preemptively loosen the muscle.
 Hip and knee stretches utilizing the fair (flexion, abduction, internal
rotation) position are done in the sitting and standing positions to
effectively relax the tight piriformis.
 After stretching it is important to incorporate lumbosacral
stabilization, hip strengthening exercises, and myofascial release.
125

126.  Stretching Exercises
 Piriformis stretching exercises should be performed in order to
reinstate pain free ROM.
 To begin the stretches should be done to the tolerance of the
patient, but some general starting guidelines are 3 sets of 5-10 reps 3
times a day.
 As the patient progresses more aggressive stretching techniques can
be used such as the PNF contract relax technique.
 Some effective and easy stretches include:
 Sit with one leg straight out in front. Hold onto the ankle of your other
leg and pull it directly towards your chest.
126

127.  Lie face down and bend one leg under your stomach, then lean
towards the ground.
 Lie on your back and cross one leg over the opposite knee, pull the
bottom leg towards your stomach.
127

128.  Keep unaffected leg straight then bend the affected leg and cross
it over the straight leg. Pull the crossed leg till a stretch is felt.
128

129.  Strengthening:
 A strengthening program for the piriformis can be initiated early in
the rehabilitation process.
 When strengthening the piriformis most exercise should be done
either with the hip flexed, which is used to focus on abduction, or
with the hip in neutral which emphasizes external rotation exercises.
 Resistance can be applied in different ways, including; manually,
with weights, or with thera-bands. The patient should be advanced
as tolerated.
 Other strengthening options can include the use of D2 flexion and
D2 extension PNF diagonal patterns.
129

130.  Myofascial Release
 Tightening of the fascia is a protective mechanism that results from
an injury. As a result of the tightening the fascia loses its pliability
and becomes restricted.
 Overtime this causes poor muscular biomechanics, decreased
ROM, altered structural alignment, and decreased strength,
endurance and motor coordination.
 In order to combat this the myofacial release technique is used.
Using myofacial release the fascia is stretched allowing a re-
establishment of the health and length of the tissue.
 This will allow for a return in the mobility of the joint as well as
decreased pressure on nerves and blood vessels.
 The myofascial release is performed by using a sustained pressure to
the restricted tissue, holding for about 90 – 120 seconds. This length
of time is sufficient for lengthening changes to occur.
 This technique is then moved to a new tissue barrier and held
again. After being repeated a few times the tissue will become
softer and more movable.
130

131. Physical Therapy Protocol for Patients
With Piriformis Syndrome
1. Ultrasound 2.0 to 2.5W/cm2 applied in broad strokes
longitudinally along the piriformis muscle from the conjoint
tendon to the lateral edge of the greater sciatic foramen for
10 to 14 minutes.
2. Hot packs or cold spray at the same location for 10 minutes.
3. Stretch the piriformis muscle for 10 to 14 minutes by
applying manual pressure to the muscle’s inferior border,
being careful not to press downward, rather directing
pressure tangentially toward the ipsilateral shoulder.
4. Myofascial release at lumbosacral paraspinal muscles.
5. McKenzie exercises.
131

132. Stress fracture of the Pars
interarticularis (spondylolysis)
132

133.  Spinal instability is a common condition in patients with low back pain. It may
begin from a congenital problem, trauma, degeneration or a progressing
hypermobility.
 Pars interarticularis- the area between the superior and the inferior articulating
processes of the vertebra, that is the point at which the articulating process
approaches the pedicle.
 Stress fracture of the pars interarticularis (spondylolysis) occur in young athletes
involved in sports that require episodes of hyperextension, especially if
combined with rotation.
 Generally mean changes in the vertebral joint characterizedby increasing
degenerationof the intervertebral disc with subsequent changes in the bones
and soft tissues.
 Unilateral or bilateral stable defect in the pars interarticularis
 “CollaredScottie dog” deformity
133

134.  This condition was initially though to be congenital but
is probably an acquired overuse injury.
 Sports in which this injury is commonly seen include
gymnastics, fast bowling (cricket), tennis, dance,
weightlifting, wrestling, pole vaulting and high jump,
as well as throwing activities such as baseball
pitching, javelin, discus and hammer throw.
 The fracture usually occurs on the side opposite to the
one performing the activity, that is, left-sided fracture
in the right-handed tennis players.
134

135. 135

136. Clinical Features
The patient complains of:
 Unilateral low back ache, occasionally associated with somatic
buttock pain
 Pain that is aggravating by movements involving lumbar extension-
the athlete may describe a single episode of hyperextension that
precipitated the pain.
Occasionally, stress fracture of the pars interarticularis are
asymptomatic.
136

137. 137

138. On Examination:
 Pain is produced on extension with rotation and on extension
while standing on the affected leg.
 The athlete may often have an excessive lordotic posture
with associated spasm of the hamstring muscles.
 Palpation reveals unilateral tenderness over the site of the
fracture.
 Special Tests:
 Pain with Spring test
 SL stance test; straight leg raises may produce pain
138

139.  In cases with recent onset of pain, X-
ray may not demonstrate the
fracture. In longer standing cases, the
typical 'Scotty dog' appearance of a
pars defect is demonstrated on the
45° oblique X-ray.
 When a pars defect is suspected
clinically but plain X-ray is normal an
isotopic bone scan, or preferably a
single photon emission computed
tomography (SPECT) scan, should be
performed.
139

140.  The bone scan will demonstrate a focal area of increased uptake.
Even when the X-ray demonstrates a pars defect, a SPECT scan
should be performed to confirm the presence of an active stress
fracture.
 Patients with a positive SPECT scan result should then undergo
reverse gantry CT scanning to image the fracture. The patient
should be monitored during the healing process, both clinically and
by repeat CT scan of the fracture.
 MRI is also capable of demonstrating a pars fracture but may not be
as sensitive as a combination of a SPECT and CT scan.
140

141. 141

142. Treatment
 There is considerable variation in the recommended treatment for pars
stress fractures.
 Almost all clinicians agree on the need for restricting the athletic activity
responsible for the pain, stretching the hamstring and gluteal muscles,
and strengthening the abdominal and back extensor muscles as soon
as these can be performed pain-free. However, the use of rigid anti
lordotic bracing is debated.
 It would seem from studies that it is the stage and site of the defect
rather than the type of treatment that determines healing of the bony
defect. Pars defects can be divided into early, progressive and terminal
stages.
142

143.  The early stage is characterized by focal bony absorption or a
hairline defect on radiographic appearance. In the progressive
stage, the defect is wide and small fragments are present. Sclerotic
change indicates the terminal stage of development.
 In most cases of early stage defects, radiographic union will be
achieved, but this will only be achieved in approximately half the
progressive stage cases and virtually none of the cases with sclerotic
changes.
 A unilateral defect is more likely to heel than bilateral defects. There
is also an improved rate of union in defects at L4 compared with L5
and in lesions closer to the vertical body.
143

144.  Therefore, it is important to make an early diagnosis and commence
a treatment program consisting of rest from sport and rehabilitation.
 We believe that there should not be a set period of time but that
the patient should undergo a rehabilitation program initially
involving pain-free progressive exercises but not aggravating
activity (i.e. lumbar extension and rotation).
 When the aggravating maneuvers are pain-free and there is no
local tenderness, a gradual progressive resumption of the
aggravating activity over a period of four to six weeks should be
conducted using pain as a guide.
144

145.  O'Sullivan et al.’s landmark study of the effectiveness of a specific
exercise program emphasizing training of the transversus abdominis
and multifidus in adults with spondylolysis and spondylolisthesis
showed dramatic differences in pain scores and improved function
that was maintained for 30 months compared to a control group
who were treated with general fitness training, supervised exercise,
modalities and trunk flexion exercises.
 A core stability training program should be included in the
treatment program.
145

146.  As with any overuse injury, it is important to identify the cause or causes
and to correct them if possible. Technique adjustments should be made
to limit the amount of hyperextension and, if necessary, a brace can be
used during sporting activity.
 This injury is extremely common among young fast bowlers in cricket.
Fast bowlers use one of three techniques-side-on, front-on or a mixed
technique where the lower half of the body is front-on and the upper
half side-on.
 It is this latter combined technique that appears to be associated with
the development of stress fractures of the pars interarticularis. The
bowler and coach should be advised to change to either a side-on or
front-on technique.
146

147. Lumbar Spondylosis - Recommended Exercises
 Lumbar Spine Rotations
147

148.  Lumbar Spine Flexion (Knee to Chest 1)
 Lumbar Spine Flexion (Knee to Chest 2)
148

149.  Pelvic Tilt
 Bridging
 Lumbar Spine Extension
149

150. 150

151. Spondylolisthesis
151

152.  Spondylolisthesis refers to the slipping of part or all of one
vertebra forward on another.
 The term is derived from the Greek spondylos, meaning
vertebra, and olisthanein, meaning to slip or slide down a
slippery path.
 It is often associated with bilateral pars defects that
usually develop in early childhood and have a definite
family predisposition.
 Pars defects that develop due to athletic activity (stress
fractures) rarely result in spondylolisthesis.
152

153.  Spondylolisthesis is most commonly seen in children between the
ages of 9 and 14 years. In the vast majority of cases it is the L5
vertebra that slips forward on the S1.
 The spondylolisthesis is graded according to the degree of slip of the
vertebra.
 A grade I slip denotes that a vertebra has slipped up to 25% over
the body of the vertebra underlying it; in a grade II slip the
displacement is greater than 25%; in a grade III slip, greater than
50%; and in a grade IV slip, greater than 75%. lateral X-rays best
demonstrate the extent of vertebral slippage.
153

154. 154

155. 155

156. Clinical features
 Grade I spondylolisthesis is often asymptomatic and the patients
may be unaware of the defect.
 Patients with grade II or higher slips may complain of low back pain,
with or without leg pain.
 The back pain is aggravated by extension activities.
156

157. On Examination:
 On examination, there may be a palpable dip
corresponding to the slip.
 Associated soft tissue abnormalities may be present.
 In considering the treatment of this condition, it is important
to remember that the patient’s low back pain is not
necessarily being caused by the spondylolisthesis.
157

158. Treatment
Treatment of athletes with grade I or grade II symptomatic
spondylolisthesis involves:
 Rest from aggravating activities combined with abdominal and
extensor stabilizing exercises and hamstring stretching.
 Antilordotic bracing, which may also be helpful.
 Mobilization of stiff joints above or below the slip on clinical
assessment; gentle rotations may be helpful in reducing pain;
manipulation should not be performed at the level of slip.
158

159.  Athletes with grade I or grade II spondylolisthesis may return to sport
after treatment when they are pain free on extension and have
good spinal stabilization. If the symptoms recur, activity must be
ceased.
 Athletes with grade III or grade IV spondylolisthesis should avoid high
speed or contact sports. Treatment is symptomatic. It is rare for a slip
to progress; however, if there is evidence of progression, spinal
fusion should be performed.
159

160. Physical therapy to include
 Stabilization exercises - care taken to avoid extension and/or rotational forces
that may increase forces on instability. Primary multifidus and transverse
abdominal strengthening,both static and dynamic(Newsletter winter 2004).
 Mobilization/manipulation of neighboring joint stiffness to reduce stresses to
instability
 Postural education
 Conservative treatment of instability has a high rate of success, particularly with
younger patients.
 Surgical interventionis rarely neededunless the case is severe.
160

161. Conservative Management
 Stretching of hamstrings is done at regular intervals.
 Patient is advised to lie prone to control the advancement of
lordosis.
 A thoraco-lumbar-sacral orthoses is given to prevent the lordosis.
The brace has to be worn continuously.
161

162. Indications for surgical intervention
are:
 grade 3 or higher displacement
 neurological signs that do not resolve with
 conservative treatment traumatic or iatrogenic spondylolisthesis
 degenerative spondylolisthesis with gross
 instability and disabling pain.
 If surgical intervention is required a spinal fusion and laminectomy is
commonly performed. The fusion may use bone grafting and spinal
instrumentation to correct the displacement of the vertebra and
relieve pressure on neurologic tissues.
162

163. Physiotherapy Management after Surgery
 During Immobilization
 Deep breathing exercises
 Early ankle, foot and arm movements are also encouraged
 Assisted movements to knee joints are given
 Isometric exercises of gluteal muscles
 Gradually hip flexion is encouraged, but it should not exceed 60
degrees.
 During Mobilization
 Gradual mobilization of spine is initiated. The patient is encouraged to
perform functional activities and to perform all the activities of daily
living.
163

164. Now
Hand over to…
NISHANK VERMA
164

165. CAUSES OF LOW BACK PAIN
 Specific causes of LBP can be subdivided by the
position of the spine at the time of injury: neutral,
flexion, or extension.
 Neutral conditions will be discussed first. These are
defined as injuries or pain syndromes of the lower
back that occur while the lumbar spine is in a
neutral position.
 Extension-related injuries occur when the lumbar
spine is in extension.
 Flexion-related injuries occur when the lumbar spine
is in flexion.
165

166. NEUTRAL CONDITIONS
 Sprains, strains, and somatic dysfunction
 Psoas spasm/syndrome
 Piriformis (pelvic outlet) syndrome or Pseudosciatica
 Sacral torsion/shear and sacroiliac joint dysfunction
 Sacral stress fracture
166

167. EXTENSION-RELATED CONDITIONS
 Spondylolysis
 Spondylolisthesis
 Lumbar facet (arthrosis) syndrome
167

168. FLEXION-RELATED CONDITIONS
 Disc degeneration/herniation (herniated nucleus pulposus)
 Discitis and vertebral osteomyelitis
 Atypical Scheuermann kyphosis
 Slipped vertebral apophysis (apophyseal ring fractures)
 Internal disc derangement
 Thoracolumbar herniation
168

169. Sacroiliac Joint
Dysfunction
169

170. SIJ Dysfunction
 SIJ dysfunction refers to an abnormal functions (e.g. hypo- and
hypermobility) at the joint, which places stresses on structures in
or around it.
 Therefore, SIJ dysfunction may contribute to lumbar, buttock,
hamstring or groin pain.
170

171. Epidemiology and Risk factors
 Training and sporting events that require repetitive unidirectional
pelvic shear and torsional forces (e.g., skating, gymnastics, and
bowling) increase the risk of developing sacral and SI joint
dysfunction.
 A sacral shear is commonly caused by a runner who
unexpectedly steps in a hole or in an Olympic weight lifter
whose weight suddenly shifts and causes a buckling of the
opposite knee while the ipsilateral leg remains locked in place.
171

172.  Precipitating factors for the development of SIJ disorders may
include muscle imbalance between the hip flexors and
extensors or between the external and internal rotators of the
hip, leg length imbalance and biomechanical abnormalities,
such as excessive subtalar pronation.
172

173. Functional Anatomy
 The SIJ is diarthrodial (synovial anterior and fibrous posterior). Its joint surfaces
are reciprocally shaped but not congruent, have a high friction coefficient
and have two large elevations allowing interdigitation with the reciprocal
surface. (plane synovial joint)
 Age changes begin to occur on the iliac side of the joint as early as the third
decade. The joint surface irregularities increase with age and seem to be
weight-bearing related. The capsule becomes more thickened and fibrous
with age. SIJ motion is best described as a combination flexion and
extension, superior and inferior glide and anterior and posterior
translation(video).
 SIJ motion is minimal, with approximately 2.5º of rotation, 0.7 mm (0.3 in.) of
translation, and it is best regarded as a stress-relieving joint in conjunction with
counterpart and the pubic symphysis.
173

174. 174

175.  In the normal gait cycle, there are combined activities that occur
conversely in the right and left innominate bones, and function in
connection with the sacrum and spine.
 Throughout this cycle there is also rotatory motion at the pubic
symphysis, which is essential to all normal motion through the joint. In
static stance, when one bends forward and the lumbar spine regionally
extends, the sacrum regionally flexes with the base moving forward and
the apex moving posterior.
 During this motion, both innominates go into a motion of external
rotation and out-flaring. This combination of motion during forward
flexion is referred to as nutation of the pelvis. The opposite occurs in
extension and is called counternutation.
175

176.  Osteopaths describes a number of dysfunctions associated with
hypomobility:
1. Innominate shears, superior and inferior
2. Innominate rotations, anterior and posterior
3. Innominate in-flare and out-flare
4. Sacral torsions, flexion and extension
5. Unilateral sacral lesions, flexion and extension.
176

177. 177

178.  Vleeming and colleagues have describe their integrated model of
joint dysfunction. It integrates structure (form and anatomy),
function (forces and motor control) and the mind (emotions and
awareness). Integral to the biomechanics of SIJ stability is the
concept of a self-locking mechanism. The ability of the SIJ to self-
lock occurs through two types of closure: form and force.
 Form closure describes how specifically shaped, closely fitting
contacts provide inherent stability independent of external load.
Force closure describes: how external compression forces add
additional stability. The fascia and muscles within the region provide
significant self-bracing and self-locking to the SIJ and its ligaments
through their cross-like anatomical configuration.
178

179. The cross like configuration
demonstrating force closure of SIJ
 This is formed ventrally by the external abdominal obliques, linea
alba, internal abdominal obliques, transverse abdominals; dorsally
the latissimus dorsi, thoracolumbar fascia, gluteus maximus and
iliotibial tract contribute significantly.
 Vleeming et al. further proposed that the posterior layer of thoraco
lumbar fascia acted to transfer load from the ipsilateral latissimus
dorsi to the contralateral gluteus maximus.
 This load transfer is through to be critical during rotation of the trunk,
helping to stabilize the lower lumbar spine and pelvis.
179

180. 180

181.  A connection has also been show between the biceps femoris
muscle and the subcutaneous ligament allowing the hamstring
to play an integral role in the intrinsic stability of the SIJ.
 The biceps femoris, which is frequently found to be shortened on
the side of the SIJ dysfunction, may act to compensate to help
stabilize the joint.
181
N.B.

182. Biomechanics
 The function of the SI joint is stability, which facilitates a safe load
transfer through the lumbo sacral pelvic complex.
 Any muscle imbalance in this region can lead to SI joint
dysfunction, which can result in a torsion or shear.
182

183. Clinical Features
 The patient with SIJ pain classically describes low back pain below
L5.
 The pain is usually restricted to one side but may occasionally be
bilateral.
 SIJ disorders commonly refer to the buttock, groin and posterolateral
thigh. Occasionally, SIJ pain refers to the scrotum or labia.
183

184.  Broadhursrt describes a clinically useful description of pelvic/SIJ
dysfunction.
 Clinically, the patient has deep-seated buttock pain, difficultly in
negotiating stairs and problems rolling over in bed, with a trial of
signs-pain over the SIJ, tenderness over the sacrospinous and
sacrotuberous ligaments, and pain reproduction over the pubic
symphysis.
184

185. Causes of Sacroiliac Joint
Dysfunction
 Some of the most common and significant sources of LBP include
sacral torsion, shear of the sacrum, or derangement of the SI joint.
 Because of the biomechanics and load translation that occur
through this joint, the dysfunction or loss of sacral motion will cause
pain and dysfunction elsewhere (e.g., in the lumbosacral segments
or the hip joint) as the body attempts to maintain normal function.
 Additionally, distant anatomic or mechanical alterations such as
physiologic leg-length discrepancy, muscle imbalance
(predominately the contralateral gluteus maximus and the latissimus
dorsi in an attempt to stabilize the incompetent joint), trunk or hip
flexibility, or improper sport-specific technique may lead to sacral
and SI joint mechanics that result in injury and pain.
185

186.  Of the three transverse axes of the sacrum (superior, middle, and
inferior), the middle axis is primarily involved in sacral dysfunctions.
 A sacral shear is a nonphysiologic dysfunction that occurs as a result
of a sudden downward force of the sacrum in combination with an
equal or greater upward force on the ipsilateral leg.
 A key to discriminating a sacral shear from a simple SI joint
dysfunction is the lack of pain referred above the L5 level in sacral
dysfunction.
186

187. History
 Athletes will normally complain of pain in the SI joint, with pain
focused around the posterior superior iliac spine and the sacral
sulcus.
 Pain may be exacerbated during repetitive overload activities,
transitional movements, or unsupported sitting. The patient may sit
on the opposite buttock in an attempt to alleviate his or her
symptoms.
 A patient who is found to have a sacral torsion or shear may
complain of pain in the SI region contralaterally as well as pain in
the mid back or even the neck, resulting from spinal compensation
for an unleveled base as the body attempts to keep the eyes level
with the horizontal.
187

188. Examination
 The physical examination of a sacral torsion consists of both the seated and
standing flexion tests to determine if an SI or iliosacral dysfunction exists.
 The examiner must determine the rotation and axis of the dysfunction by
bilaterally palpating the sacral sulcus (base) with his or her thumbs: the thumb
that is more anterior by palpation is the deeper sulcus.
 He or she must palpate the inferior lateral angles of the sacrum: the thumb
that is more posterior and, by convention of sacral mechanics, more inferior is
the posterior inferior lateral angle.
 Innominate compression can be performed with the patient lying supine: the
innominate that does not move freely or that elicits pain at the SI joint when
equal, posterior force is placed on the anterior superior iliac spines is the
dysfunctional side.
 Using this information, the physician can determine the athlete’s type of
sacral dysfunction.
188

189.  To test for a sacral shear, the practitioner places his or her thumbs on the soft
tissue below the gluteus on either side of the coccyx and pushes cephalad
with light pressure until the thumbs strike the caudal surface of the sacrum on
each side of the coccyx: the more inferiorly displaced inferior lateral angle is
ipsilateral to the sacral shear.
 In addition, in sacral shear dysfunction, no motion will be felt at the ipsilateral
inferior pole of the SI joint. Palpation of the ipsilateral sacrotuberous ligament
will reveal it to be lax as a result of the bony approximation of the sacrum and
the ischium.
 Finally, to test gross SI joint motion, the patient is placed prone with the
affected side leg flexed to 90 degrees at the knee. While one hand abducts
the athlete’s leg, the other monitors for gapping of the SI joint just medial to
the posterior superior iliac spine ipsilaterally. The side with the sacral shear will
not gap.
189

190.  The physical examination of the SI joint is extensive, and numerous tests have
developed that induce shearing or rotational forces to stress inflamed
structures, thus provoking pain.
 The most common provocation and motion tests for the sacrum and SI joint
include the compression test; the distraction (gapping) test; the Gaenslen
sign; the flexed, abducted, externally rotated (FABER) test (i.e., Patrick’s or
figure four test); the flexed, adducted, internally rotated (FADIR) test; Gillet’s
test; the Lesegue sign; the posterior shear (POSH) test; the resisted abduction
(REAB) test; the WilsonBarstow test; and the Yeoman test. (pdf)
 However, for SI joint assessment, a combination of the FABER, POSH, and
REAB tests has a high predictive value in diagnosing SI joint dysfunction, with
a sensitivity ranging from 77% to 87% and a specificity approaching 100%.
190

191. 191
1 2 3
4 5 6

192. 192

193. Diagnostic Imaging
 All types of imaging studies (plain radiographs, CT scanning, MRI,
bone scintigraphy, and SPECT) have proven to be of little value for
diagnosing SI joint and sacral dysfunctions.
 However, if an infectious, metabolic, fracture, or neoplastic
condition is suspected, or if symptoms persist after a trial of
conservative and manipulative treatment, imaging of the SI joint
should be performed.
 Multiple authors report intra-articular injections, primarily under
fluoroscopic guidance, as the gold standard for diagnosing the SI
joint dysfunction.
193

194. Treatment
 Due to the complex nature of the SIJ and its surrounding structures, treatment
must focus on the entire abdomino-lumbo-sacro-pelvic-hip complex, addressing
articular, muscular, neural and fascial restrictions, inhibitions and deficiencies.
 Core stability training should be included. A recent study has suggested that the
clinical benefits incurred with training the transversus abdominis muscle may be
due to significantly reduced laxity in the SIJ. Exercise rehabilitation is an integral
part of recovery from SIJ dysfunction.
 Pelvic or SIJ dysfunction should be considered with the lumbar spine in any
program designed to improve the overall control of the lumbopelvic area.
Stretching and soft tissuetherapy are useful in correcting pelvic/SIJ imbalance.
 The most common soft tissue abnormalities found with unilateral anterior tilt are
tight psoas and rectus femoris muscles.
194

195.  Muscle energy techniques may also be helpful, as may osteopathic
manipulation.
 Trochanteric belt (sacroiliac Belts) may be used to stabilize the joint.
These belts have not been shown to be particularly helpful.
 Biomechanical proprioceptive retraining should be done to
maintain sacral and SI joint function.
 If these manual techniques fail to control the sacroiliac pain,
injection therapy may prove useful.
195

196. 196

197.  Exercises to improve SI joint stabilization should include those that
isolate the transverses abdominus, multifidus, and piriformis as well as
those that strengthen the coordination between the contralateral
gluteus maximus and the latissimus dorsi.
 A combination of local anesthetic and corticosteroid agents may
be injected into the region of the SIJ either with or without
fluoroscopic guidance. Sclerosants are occasionally used when
hypermobility is present, sometimes referred to as prolotherapy.
197

198. PHASE I - SIJ Pain Relief & Joint
Protection
 Managing your sacroiliac pain is the main reason that you seek
treatment for sacroiliac joint dysfunction. In truth, it was actually
the final symptom that you developed and should be the first
symptom to improve.
 Managing your inflammation. Sacroiliac joint inflammation it
best eased via ice therapy and techniques or exercises that
deload the inflammed structures. Your doctor may recommend
a course of non-steroidal anti-inflammatory drugs such as
ibuprofen.
 Your physiotherapist will use an array of treatment tools to
reduce your sacroiliac pain and inflammation. These include:
ice, electrotherapy, acupuncture, deloading taping techniques,
a SIJ belt, soft tissue massage and temporary use of a mobility
aid (e.g. cane or crutch) to off-load the affected side.
198

199. PHASE II - Restoring Normal ROM,
Strength
 As your pain and inflammation settles, your physiotherapist will turn
their attention to restoring your normal pelvic alignment and
sacroiliac joint range of motion, muscle length and resting tension,
muscle strength and endurance, proprioception, balance and gait
(walking pattern).
 Your physiotherapist will commence you on a lower abdominal
and hip core stability program to facilitate your important muscles
that dynamically control and stabilize your sacroiliac joints.
 Researchers have discovered the importance of your hip muscle
recruitment patterns with a normal order of: deep, then
intermediate and finally superficial muscle firing patterns in normal
pain-free hips.
 Your physiotherapist will assess your muscle recruitment pattern and
prescribe the best exercises for you specific to your needs.
199

200. PHASE III - Restoring Full Function
 As your sacroiliac joint dynamic control improves, your
physiotherapist will turn their attention to restoring your normal
pelvic alignment and sacroiliac joint range of motion during
more stressful positions and postures plus work on your muscle
power, proprioception, balance and gait (walking pattern).
 Depending on your chosen sport or activities of daily living, your
physiotherapist will aim to restore your SIJ function to safely allow
you to return to your desired activities.
 Everyone has different demands for their sacroiliac joints that will
determine what specific treatment goals you need to achieve.
For some it be simply to walk around the block. Others may wish
to run a marathon.
 Your physiotherapist will tailor your sacroiliac joint rehabilitation
to help you achieve your own functional goals.
200

201. PHASE IV - Preventing a Recurrence
 Sacroiliac joint dysfunction does have a tendency to return. The
main reason it is thought to recur is due to insufficient
rehabilitation. In particular, poor compliance with deep
abdominal and hip core muscle exercises. You should continue
a version of these exercises routinely a few times per week.
 Your physiotherapist will assist you in identifying the best exercises
for you to continue indefinitely.
 In addition to your muscle control, your physiotherapist will assess
you SIJ, spine, hip and lower limb biomechanics and correct any
defects. (whole kinetic chain)
 It may be as simple as providing you with adjacent muscle
exercises or some foot orthotics to address any biomechanical
faults in the legs or feet.
201

202. 202

203. Lumbar facet
dysfunction
203

204. Description
 Lumbar facet syndrome means: A dysfunction at the level of the
posterior facet joints of the spine. These joints together with the
disc form the intervertebral joint. Changes at the level of the
posterior facet joints can influence the disc and vice versa.
 Lumbar facet (arthrosis) syndrome (chondromalacia facetiae),
which was described by R.K. Ghormley in 1933, is a
chondromalacial condition that occurs at the zygapophyseal
joint.
 The term ‘dysfunction’ implies that at a certain level (mostly L4-L5
or L5-S1) these components do not function normally.
204

205.  The lumbar facet syndrome is a painful irritation of the posterior part
of the lumbar spine. Swelling from the surrounding structures, can
cause pain due to an irritation of the nerve roots.
 Little capsular tears can originate at the level of the posterior facet
joints due to a trauma. This can lead to a subluxation of the joint. The
Synovium that surrounds the joint is damaged and leads to a
synovitis.
 Secondly a hypertonic contraction of the surrounding muscles
present itself. This is a protection mechanism that increases the pain.
These changes lead to a fibrosisand osteophyte formation.
205

206.  The most common cause is repetitive micro trauma and as positive
result of this chronic degeneration. In daily living this may occur with
repetitive extension of the back. So mostly all movements with the
arms above the head.
 These recurring injuries can happen in sports were it is necessary to
make repetitive powerful hyperextensions of the lumbar spine.
 An irritation can also occur when the intervertebral disc is damaged
and the biomechanics of the joint have changed. In this case the
facet joints are exposed to a higher loading.
206

207. Epidemiology
 The lumbosacral facet joint is reported to be the source of pain in 15-40% of
patients with chronic LBP. Ray believed that facet joint–mediated pain is
the etiology for most cases of mechanical LBP, whereas other authors have
argued that it may contribute to nearly 80% of cases.
 Thus, the diagnosis and treatment of this entity may help alleviate LBP in a
significant number of patients.
 This condition most commonly occurs among older athletes, but it can be
seen as early as late adolescence, predominantly among football lineman
and weight lifters, who subject their spines to tremendous axial and
torsional loads.
207

208. Pathophysiology and mechanism
of injury
 Asymmetric angulation of facet joints that are subjected to
increased axial loads produces stresses that are sufficient to
cause articular cartilage damage.
 With repeated microtrauma, fracturing of the articular surface
occurs, with subsequent erosion of the underlying bony surface
(eburnation).
208

209. Clinical Features
 Local pressure pain at the level of the affected joint
 Local pressure pain of the M. Multifidi and M. Erector Spinae
(when palpating very stiff due to hypertonia)
 Decreased extension and painful extension
 Unilateral abnormal lateroflexion
 Antalgia can occur when rising up with a flexed torso
 Sometimes a functional scoliosis in anteflexion
209

210.  sensibility/pain local and ipsilateral
 pain in hyperextension
 pain in hip, bottom and back when liftinga extended leg (SLR)
 referred pain not further than the knee
 local stiffness
 Kemp’s test positive
 Springing test positive
Pain: mild to severe, different between patients and within patient.
Pain variant during different positions.
210

211. Increase pain
- Extension
- Rotation
- Prolonged standing
- Sudden movements
- After rest
- Lateral flexion towards affected side
- Returning from flexed position
- Movements in general
- Sitting, flexion, using a clutch (in a vehicle), coughing and/or
sneezing, and walkingfor a long time
211

212. Decrease pain
- Walking
- Lying with knees bent
- Medication
- Supported flexion, sitting, standing with weight on hands and
elbows
- Rest
- Lateral bending towards healthy side
- Varying activity
212

213. History & other findings
 No characteristic pain pattern or level-specific signs and symptoms
have been found to be specific for the diagnosis of lumbar facet
syndrome.
 Patients commonly present with pain upon rising or when
performing lumbar flexion and with point tenderness in the
paraspinous region over the affected facet joint.
 Referred pain, when occassionally present, extends to the thigh but
not below the knee.
 Other common findings are tightened hamstrings and a positive
Gowers sign (the hands incrementally stepping up the thighs to
support the upper torso when rising).
213

214. Imaging Studies
 Radiographic imaging during the latter stages of this condition
demonstrates changes that are indicative of facet arthrosis.
 However, this finding is relatively uncommon during the early stages
of disease, and it is therefore of little diagnostic value.
 CT scanning provides detailed imaging of the facet joint chondral
surfaces, and it can delineate areas of cartilaginous damage.
214

215.  Lumbar Facet syndrome can not be reliably clinically diagnosed (Jackson
RP2 1992). The most used systems to diagnose this syndrome are an X-ray, a
computed tomography (CT) scan of the spine or a magnetic resonance
imaging (MRI) scan.
 The working diagnosis of facet pain, based on history and clinical
examination, may be confirmed by performing a diagnostic block. This is
considered positive when the patient experiences a 50% pain reduction.
 It involves injecting a medicine into or near the nerves that supply the facet
joint. If the pain is not relieved by the injection, it is unlikely that the facet
joint is the source of the pain. If these injections help and reduce the pain,
we can suggest that the pain comes from the facet joint.
215

216. Although no single sign or symptom is diagnostic, Jackson et al; demonstrated
that the combination of the following 7 factors was significantly correlated with
pain relief from an intra-articular facet joint injection:
 Older age
 Previous history of LBP
 Normal gait
 Maximal pain with extension from a fully flexed position
 The absence of leg pain
 The absence of muscle spasm
 The absence of exacerbation with a Valsalva maneuver
216

217. Differential Diagnosis
 Lumbosacral Disc Injuries
 Lumbosacral Discogenic Pain Syndrome
 Lumbosacral Radiculopathy
 Lumbosacral Spine Acute Bony Injuries
 Lumbosacral Spine Sprain/Strain Injuries
 Lumbosacral Spondylolisthesis
 Lumbosacral Spondylolysis
 Piriformis Syndrome
 Sacroiliac Joint Injury
 Inflammatory arthritidies (ex. rheumatoid arthritis)
 Spondylarthropathies (ex. osteoarthrosis, synovitis)
217

218. Examination
Inspection
Inspectionshouldinclude an evaluation of paraspinal musclefullness or
asymmetry,increaseor decrease in lumbar lordosis, muscleatrophy, or
posture asymmetry.
Patients with chronicfacet syndromemay have flattening of the lumbar
lordosis and rotation or lateral bending at the sacroiliac joint or
thoracolumbar area.
Palpation
The examiner shouldpalpate along the paravertebral regions and directly
over the transverseprocesses because the facet joints are not truly
palpable. This is performedin an attempt to localizeand reproduce any
point tenderness,whichis usuallypresent with facet joint–mediatedpain.
In some cases, facet joint–mediatedpain may radiate to the gluteal or
posterior thigh regions.
Sensory examination
Sensory examination(i.e, light touch and pinprickin a dermatomal
distribution) findings are usually normal in persons with facet joint pathology.
218

219.  Range of motion
Range of motion should be assessed through flexion, extension,
lateral bending, and rotation.
With facet joint–mediated LBP, pain is often increased with
hyperextension or rotation of the lumbar spine, and it might be
either focal or radiating.
 Flexibility
Inflexibility of the pelvic musculature can directly impact the
mechanics of the lumbosacral spine.
With facet joint pathology, the clinician may find an abnormal
pelvic tilt and rotation of the hip secondary to tight hamstrings, hip
rotators, and the quadratus, but these findings are nonspecific and
can be found in patients with other causes of LBP.
219

220.  Muscle stretch reflexes
Patients with facet joint–mediated LBP usually have normal muscle
stretch reflexes. Radicular findings are usually absent unless the patient
has nerve root impingement from bony overgrowth or a synovial cyst.
Side-to-side asymmetry should lead one to consider possible nerve root
impingement.
 Muscle strength
Manual muscle testing is important to determine whether weakness is
present and whether the distribution of weakness corresponds to a
single root, multiple roots, or a peripheral nerve or plexus.
Typically, manual muscle testing results are normal in persons with facet
joint pathology; however, subtle weakness of the muscles of the pelvic
girdle may contribute to pelvic tilt abnormalities. This subtle weakness
may be appreciated with trunk, pelvic, and lower-extremity extension
asymmetry.
 Straight leg – raise test
This maneuver is usually normal for facet joint–mediated pain.
However, if facet joint hypertrophy or a synovial cyst encroaches on
the intervertebral foramen, causing nerve root impingement, this
maneuver may elicit a positive response.
220

221. Special test for LBA due to facet joint
 Kemp’s test &
Springing test
Rx:-
 The pharmacological therapy used by doctors for acute back pains
caused by facet joint syndrome is based on administrating muscle
relaxants.
 In medicine they also use nonsteroidal anti-inflammatory drugs and
acetaminophen as first line drugs for the treatment of LBP, with little
evidence to support one particular drug over another.
 Standard treatment modalities for facet joint syndrome pain include
intraarticular steroid injections and radiofrequency denervation of
the medial branches innervating the joints. Yet there is much
controversy in scientific articles related to this standard treatment.
221

222. Physical Therapy Management
 When acute signals have disappeared, the underlying cause is treated by
physiotherapy:
 The first thing you need to do is to inform your patient. He needs to understand the
problems he is having. You may not make him anxious, so a diplomatic approach is
necessary to prevent him from catastrophizing. When he is anxious when he needs to
move, you cannot do exercises. So the kinesiophobia needs to be banned.
 Now you can start with the exercises. When your patient is having an antalgic posture,
this needs to be treated by giving instructions how he has to keep his back in the right
position/straight. He has to keep all physiological curves in his back (cervical lordosis,
thoracic kyphosis, lumbar lordosis).
 Instructions are not only important for passive activities, like sitting and standing, but also
for active movements. So when he does a certain movement, he can take a certain
posture to which will not provoke his symptoms.
 As therapist you can do passive modalities. You can mobilize the lower back of your
patient. In a later stage of the therapy, you can manipulate the lower back.
222

223. The initial treatment for acute facet
joint pain is focused on:
 Education
 Maintenance of positions that provide comfort
 Reducing lumbar lordosis
 Relative rest
 Pain relief
 Exercises
223

224.  Therefore it is important to reduce excessive lumbar lordosis with
exercise because excessive lordosis increases loading on the posterior
aspect of the spine, including the z-joints. To achieve this, the patient
should be taught pelvic maneuvers to reduce the degree of lumbar
lordosis.
 These pelvic tilt exercises can be performed in multiple positions such as
sitting, standing with knees bent or straight legs.
 Bed rest beyond 2 days isn’t recommended as it can have undesirable
effects on bones, connective tissues, muscles and the cardiovascular
system. (discussed earlier)
 The patient is encouraged to limit activity on days when the symptoms
are not tolerable, but should never be completely inactive. Therapist
must strive to influence the patient to be as active as possible.
224

225.  Bronfort G. et al. (1996) studied the relative efficacy of three
different treatments for chronic low back pain. They comprised
followed combinations: spinal manipulative therapy (SMT)
combined with trunk strengthening exercises (TSE) vs. SMT combined
with trunk stretching exercises and SMT combined with TSE vs. non-
steroidal anti-inflammatory drug (NSAID) therapy combined with TSE.
 During 11 weeks (5 weeks under supervising and 6 weeks alone)
they examined: patient-rated low back pain, disability and
functional health status.
 Their conclusion was that each of the three therapeutic regimens
was associated with similar and clinically important improvements.
For the management of facet joint syndrome, trunk exercise in
combination with SMT or NSAID therapy seemed to be beneficial
and worthwhile.
225

226.  Spinal manipulation is being used for both short- and long-term pain
relief.
 Other scientific sources recommend treating facet joint syndrome
with heat, cryotherapy and mobilizations. These techniques appear
to have a relaxing effect on the muscles. As the muscles relax, the
nociceptive information will decrease.
 While these techniques have clear advantages, they generally only
attain a temporary pain relief as they are often not a final solution to
treat facet joint syndrome.
226

227.  Gerard A. Malanga et al. (2008) argue that once the painful symptoms are
controlled, stretching and strengthening exercises can be initiated. For the
stretch, the focus should be on the muscles that create excessive anterior tilt of
the pelvis.
 Stretching should not be not limited to just these muscles because all the muscles
articulating to the lumbar spine and pelvic girdle may be imbalanced, and
regular stretching can help restore productive mechanics to the lumbar spine
and pelvis.
 Therefore, stretching programs should also include the hamstrings, quadriceps,
hip abductors, gluteals, and abdominals. Stretching through dynamic postural
motions (e.g, yoga postures) can be especially helpful because the motions can
restore balance to the muscles of the lumbar spine and pelvic girdle.
 These exercises are eventually incorporated into a more extensive rehabilitation
program, which includes spine stabilization exercises The objective of these
exercises is to teach the patient how to find and maintain a neutral spine
throughout everyday activities.
227

228.  A series of 16 exercises should be performed in the same order, as described by
Moon et al (2013). Before each exercise, the physical therapist gave detailed
verbal explanation and visual instructions (pictures), regarding the start and end
positions.
 All exercises were conducted according to the following specific principles:
breathe in and out, gently and slowly draw in your lower abdomen below your
umbilicus without moving your upper stomach, back or pelvis"; resulting in a
situation referred to as hollowing.
 Subjects practiced "hollowing" with a therapist providing verbal instruction and
tactile feedback until they were able to perform the maneuver in a satisfactory
manner.
 In addition, a "bulging" of the multifidus muscle should have been felt by the
therapist when the fingers were placed on either side of the spinous processes of
the L4 and L5 vertebrae, directly over the belly of this muscle. These feedback
techniques provided by precise palpitation of the appropriate muscles, ensure
effective muscle activation.
228

229.  In the final phase of the rehabilitation, eccentric muscle strengthening
exercises and dynamic exercises are added to the program. These are to be
performed in a functional manner and in functional planes.
 All exercises were performed in the treatment room under the supervision of a
physical therapist with technical knowledge.
 The therapist put each patient into the appropriate position to achieve the
correct posture and muscle contraction.
 An important focus of the exercise therapy should be on stabilization therapy.
They are aimed to strengthen the deep lumbar stabilizing muscles: the
transversus abdominis, lumbar multifidi, and internal obliques.
229

230. Degenerative Disc
Disease (DDD)
DISC DEGENERATION OR HERNIATED NUCLEUS PULPOPUS
230

231. Description
 Degenerative disc disease or discopathy
occurs when the discs (shock absorbers)
cartilage between the bones of the spine,
subjected to a process of degeneration that causes the disc to lose height
and hydratation.
 The disc can’t fulfill his function anymore and it usually causes pain. It occurs
naturally in most people over the years and is a part of the aging process.
 The discopathy may develop at any level of the spine, but is most common in
the cervical and lower lumbar segments. These are the transitions between
mobile (cervical, lumbar) and fixed (thoracic, sacral) sections of the spine.
231

232. Clinically Relevant Anatomy
 Degenerative Disc Disease (DDD) is thought to begin
with changes to the annulus fibrosis, intervertebral disc,
and subchondral bone. The process of degeneration is
divided into three classifications including: early
dysfunction, intermediate instability, and final
stabilization.
 Early dysfunction is the classified as the beginning of
degenerative changes which can occur as early as 20
years. Intermediate instability is classified by a loosening
of the annulus fibrosis, which can cause back pain.
 Fibrosis to the posterior structure and formation of
osteophytes denotes the final stabilization process. Pain
decreases, and motion decreases.
232

233. Epidemiology
 Disc degeneration is predominately seen in the adult population as a result of
years of overuse and improper lifting techniques. Degenerative disc changes
in preadolescent gymnasts are well described in the literature, with a
reported incidence rate of 11% in pre-elite gymnasts, 43% in elite gymnasts,
and 64% in Olympic gymnasts.
 Conversely, this is a relatively uncommon injury among children who do not
participate in gymnastics. When training exceeds 15 hours per week, the risk
of injury increases from 13% to 57%.
 Other sports that are associated with disc degeneration are collision sports
(e.g., football, lacrosse, and hockey), soccer, bowling, gymnastics, weight
lifting, and wrestling.
 Of all professional sports, golfers have the highest incidence of back injury
because of the torsional stress of the golf swing wind up, swing, and follow
through.
233

234. 234

235. Etiology
 Degenerative disc disease refers to a condition in which the
involved disc causes LBP. Lumbar degenerative disc disease is
usually the result of a twisting injury to the lower back, such as
when a person swings a golf club or rotates to put an object on a
surface to the side of or behind them.
 The pain is also frequently caused by simple wear and tear on the
spine and comes with the general aging process.
 Degenerative disc disease is fairly common, and it is estimated that
at least 30% of people aged 30-50 years old will have some degree
of disc space degeneration, although not all will have pain or ever
receive a formal diagnosis.
235

236.  The process that leads to DDD begins with structural changes. The
annulus fibrosis (outer portion of the disc) loses water content over
time which will make it increasingly unyielding toward everyday
stress and strain on the spine.
 The loss of compliance in the discs contributes to forces being
redirected from the anterior and middle portions of the facets to the
posterior aspect, thus causing facet arthritis.
 Another result is hypertrophy of the vertebral bodies adjacent to the
degenerating disc. The overgrowths are known as bony spurs or
osteophytes (final stabilization process).
236

237. Characteristics
DDD commonly occurs with other diagnoses such as:
 idiopathic low-back pain
 lumbar radiculopathy
 myelopathy
 lumbar stenosis
 spondylosis
 osteoarthritis
 zygapophydeal joint degeneration
237

238. Activities that typically increase pain include:
 Sitting for extended periods of time
 Rotating, bending, or lifting
Activities that typically decrease pain include:
 Changing positions often
 Lying down
 Staying active
238

239. Grades
 There are different degrees of annular disruption. We can classify
them into 4 grades, at which grade 0 is added. We differentiate
these grades by means of a contrast medium injection.
 Grade 0: no disruption
 Grade 1: the contrast medium passes into the cartilage endplate
through tear
 Grade 2: the contrast medium flows into the bony endplate
 Grade 3: the contrast medium is going into the cancellous bone of
vertebrae under endplate
 Grade 4: the contrast medium leaks completely in the cancellous
bone.
239

240. 240

241. Pathogenesis and mechanism of
injury
 A number of hypotheses have been developed to clearly define
the mechanism of disc degeneration. One of the most convincing is
the ‘‘wear-and-tear’’ hypothesis, which proposes that localized
microtrauma from repeated lateral bending, rotational torque, and
axial loading during repetitive movements of the lumbar region
cause injury to the intervertebral disc.
 In vitro studies have demonstrated that the application of static
loads can induce cell apoptosis, alter structural disc properties
(thickness, axial compliance, and angular laxity), change matrix
content (proteoglycan and type I/II collagen), interfere with
metalloproteinase activity, and alter gene expression (aggrecan
and collagen II).
241