Principles of Management for the Spine
At the time of a low back or cervical injury, impairments, activity limitations, and participation restrictions are not known. Up to 60% of acute back injuries resolve within 1 week and up to 90% resolve within 6 weeks83 with a recurrence rate of less than 25%.14 Disabilities are dependent on the extent of the injury. If it involves the spinal cord, levels of complete paralysis may occur. If it involves the nerve roots (also the cauda equina), varying degrees of sensory loss in specific dermatomes and muscle weakness in specific myotomes may occur, which may or may not interfere with the individual's daily personal and work-related activities. Upper-quarter nerve roots affect function of the arms and hands; lower-quarter nerve roots affect function of the lower extremities, especially during weight-bearing activities. Studies on chronic pain syndromes as a result of back injuries seem to conclude that the degree of disability is related to psychological, economic, and sociological factors and prior incidence of injury more than the actual tissues involved.64,91 Nerve root involvement and pain provocation with active movements in several directions are more common in patients who develop chronic pain.64 Discussion of treatment for spinal cord injuries and chronic pain syndromes is beyond the scope of this book.
Examination and Evaluation
History, systems review, and testing. A history and systems review of the patient is conducted to rule out any serious conditions, determine if the patient should be referred to another practitioner, or determine if the patient's condition is appropriate for physical therapy intervention. Then, if it is safe, tests and measures are conducted to determine if the source of symptoms can be influenced by mechanical changes in position or movement and to establish a baseline of impairment and functional limitations measurements from which changes can be documented. Examination techniques and procedures are beyond the scope of this text, but a brief summary of concerns in the spinal area is listed to help focus on critical decisions prior to establishing an intervention strategy.
Serious "red flag" conditions related to orthopedic conditions that should be referred to a physician for management include spinal cord symptoms and signs (upper motor neuron lesions), recent trauma in which spinal fracture or instabilities have not been ruled out, and serious pain (especially pain that awakens the individual) that cannot be explained mechanically.
Psychological distress may interfere with a patient's recovery; therefore, referral to an appropriate professional may be indicated for a multidisciplinary approach in the patient's care.
Neurological symptoms should be explored in an attempt to relate them to spinal cord, nerve root, spinal nerve, plexus, or peripheral nerve patterns. Causes of nerve root signs frequently seen by physical therapists include intervertebral disc protrusions; boney, soft tissue, or vascular stenosis in the spinal canal or intervertebral foramina; facet joint swelling; and nerve root tension from restricted mobility or inflammation.
Pain patterns should be explored to determine if they relate to a known musculoskeletal pattern or signal a medical condition. It should be recognized that pain is interpreted in many ways and has various meanings for different people; therefore, the information is interpreted as only one factor when determining cause of the symptoms.
Stage of recovery. Time frames for each recovery stage vary depending on the reference used. In general, the acute stage usually lasts less than 4 weeks; the subacute stage is 4 to 12 weeks; and the chronic stage is greater than 12 weeks.2 Chronic pain syndromes generally are conditions that extend beyond 6 months.
Acute inflammatory stage. The patient experiences constant pain, and there are signs of inflammation. No position or movement completely relieves the symptoms. Medical intervention with anti-inflammatory medications is usually warranted.
Acute stage without signs of inflammation. Symptoms are intermittent and related to mechanical deformation. There may be signs of nerve irritability when the nerve root or spinal nerve is compressed or placed under tension. The patient may be categorized into an extension bias, a flexion bias, or a nonweight-bearing bias based on the presenting posture, movement impairments, or positions of symptom relief. These categories are described in greater detail in the next section. Delitto and associates33 classified patients as being at this stage if they cannot stand longer than 15 minutes, sit longer than 30 minutes, or walk more than one-quarter mile without their status worsening.
Subacute stage. Usually at this stage, certain movements and postures with some instrumental activities of daily living (IADLs) still provoke symptoms, such as lifting, vacuuming, gardening, and other activities requiring repetitive movement of loads, so a basic lifestyle cannot fully be resumed. A more thorough examination is conducted to identify specific activity and participation restrictions and impairments that could be interfering with recovery.
Chronic stage. When this stage is reached, emphasis is placed on returning the patient to high-level demand activities that require handling repetitive loads on a sustained basis over a prolonged period of time (from heavy material handling, to repetitive household activities that include lifting small children, to strenuous athletic activities).
Diagnosis, prognosis, and plan of care. As mentioned in the introduction to this chapter, specific pathologies and medical diagnoses often do not guide the therapist when choosing appropriate treatment interventions, and various systems of patient classification for treating musculoskeletal impairments and functional limitations are present in the literature.2,33,34,48,101,138,145 In addition, validation studies supporting clinical prediction rules are available to assist the therapist in making decisions when developing and modifying interventions.9,24,26,27,49,66,93,136,154 The material in the remainder of this section is organized to integrate impairment-based diagnostic categories with the medical model of spinal pathologies in order to help the therapist choose an intervention strategy that best enhances the patient's recovery. Specific medical diagnoses with unique regional features and interventions are described in the last section of this chapter.
The decisions concerning the approach to treatment are determined by the patient's responses to the examination maneuvers and the maneuvers that provide the greatest relief of symptoms. Adjustments in the intervention occur as the patient progresses through the healing process. The categories described in this and the following sections are summarized in Box 15.4.
BOX 15.4 Impairment-Based Diagnostic Categories That Direct Intervention33,48,101,138 General: Stage of Recovery
Nonweight-Bearing Bias: Traction Approach
Acute with inflammation (0–4 weeks).
Acute without inflammation (0–4 weeks): intermittent symptoms with acute nerve root symptoms.
Subacute (4–12 weeks).
Chronic (>12 weeks).
Chronic pain syndrome (>6 months).
Extension Bias: Extension Approach
Patient does not tolerate being upright for basic ADLs and IADLs.
Movement testing makes symptoms worse.
Traction (or other nonweight-bearing procedures) relieves symptoms.
Flexion Bias: Flexion Approach
Patient usually presents with flexed posture—a lateral shift may also be present.
Extension tests decrease or centralize symptoms.
Diagnosis may include intervertebral disc lesions, impaired flexed posture, fluid stasis.
Hypermobility/Functional Instability: Stabilization/Immobilization Approach
Patient usually presents with flexed posture and is more comfortable when flexed.
Extension tests exacerbate or peripheralize symptoms.
Diagnoses may include spondylosis, stenosis, extension load injuries, swollen facet joints.
Hypomobility: Mobilization/Manipulation Approach Muscle and Soft Tissue Lesions: Exercise Approach
Patients present with hypermobile spinal segment(s); poor spinal stability (segmental or global).
Diagnoses may include trauma, ligamentous laxity, spondylolysis, or spondylolisthesis.
Postural Pain Syndrome: Exercise and Conditioning Approach
Patient usually presents with guarded posture or increased muscle tension.
Diagnoses may include strains, tears, contusions, or overuse.
Patient presents with faulty posture; symptoms increase with sustained position.
Diagnoses may include postural strain, cervico-genic headache, thoracic outlet syndrome, poor physical condition
Movement, posture correction, and exercise decrease symptoms
FOCUS ON EVIDENCE
Audrey and associates9 studied 312 acute, subacute, and chronic patients with low back pain (with or without sciatica). They found significantly greater improvement in outcomes for individuals whose exercise interventions were matched with their directional preference (flexion, extension, or side glide/rotation) than those who undertook nondirectional exercises.
Long93 identified patients with chronic low back pain as either centralizers (peripheral symptoms lessened or became more proximal) or noncentralizers as a result of repeated movement tests. Long concluded that those who were classified as centralizers had greater improvement in outcome measures (pain rating, return to work rate) than noncentralizers.
General Guidelines for Managing Acute Spinal Impairments: Protection Phase
Use of modalities and massage to decrease pain and swelling from acute symptoms is appropriate during the acute stage. It is also important that the patient becomes an active participant in his or her program. Kinesthetic training of neutral or functional spinal posture, nondestructive movements in the pain-free range, awareness and activation of deep segmental musculature, and basic functional training maneuvers are taught if they do not exacerbate the symptoms. Specific interventions for various impairments, specific biases, or syndromes and common pathologies in the spinal region are described in the remaining sections of this chapter. Specific techniques for kinesthetic training, deep segmental muscle activation, stabilization training, joint manipulation, and functional training activities for the acute stage in the cervical and lumbar spinal regions are described in Chapter 16. Management guidelines for treating the patient with acute symptoms are summarized in Box 15.5. The following points are fundamental to all interventions.
BOX 15.5 MANAGEMENT GUIDELINES—Acute Spinal Impairments/Protection Phase Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations)
Pain and/or neurological symptoms
Inability to perform ADLs and IADLs
Guarded posture (prefers flexion, extension, or nonweight-bearing)
|Plan of Care ||Intervention |
|1. Educate the patient. ||1. Engage patient in all activities to learn self-management. Inform patient of anticipated progress and precautions. |
|2. Decrease acute symptoms. ||2. Modalities, massage, traction, or mobilization/manipulation as needed. Rest only for first couple days if needed. |
|3. Teach awareness of neck and pelvic position and movement. ||3. Kinesthetic training: cervical and scapular motions, pelvic tilts, neutral spine. |
|4. Demonstrate safe postures. ||4. Practice positions and movement and experience effect on spine. Provide passive support/bracing if needed. |
|5. Initiate neuromuscular activation and control of stabilizing muscles. || |
5. Deep segmental muscle activation techniques:
Basic stabilization: with arm and leg motions (passive support if needed, progress to active control).
|6. Teach safe performance of basic ADLs; progress to IADLs. ||6. Roll, sit, stand, and walk with safe postures. Progress tolerance to sitting longer than 30 minutes, standing longer than 15 minutes, and walking > 1 mile. |
It is important to engage patients in all aspects of intervention, including information about anticipated progress and outcome, the healing time of inflamed tissues or reduction of symptoms due to nerve root pressure (if indicated), and precautions and contraindications.
Symptom Relief or Comfort
If a patient is experiencing acute inflammation from a traumatic injury, there is constant pain; yet, often an optimal position of comfort or symptom reduction can be determined in which there is the least amount of stress on the inflamed, irritated, or swollen region. The terms functional position or functional range are used to describe this position.109 (Neutral position is mid-range.) The functional range may change for the individual as the tissues heal and the person gains mobility and strength in the region. Some pathological conditions typically tend to cause symptoms in one portion of the range and are relieved in another range.109 The following terms, describing subcategories of diagnoses or syndromes, have been popularized based on the work of Morgan,109 Saal and associates,140,142 Delitto and colleagues,33 and Fritz and George.48
Extension bias-extension syndrome. The patient's symptoms are lessened in positions of extension (lordosis). Sustained flexed postures or repetitive flexion motions load the anterior disc region, causing fluid redistribution from the compressed areas and swelling and creep in the distended areas. This is frequently the mechanism of symptom production with posterior or posterolateral intervertebral disc lesions or injury to the posterior longitudinal ligament. Whether the pathology is an injured disc or stressed and swollen tissues, repeated extension motions and positions relieve the symptoms by moving the fluid to reverse the stasis. These techniques are described in the section 'Extension Bias.' Some patients present with a lateral shift, which usually requires correction before extension relieves the symptoms.101,102,103
Flexion bias-flexion syndrome. The patient's symptoms are lessened in positions of spinal flexion and provoked in extension. This is often the case when there is compromise of the facets, intervertebral foramen, or spinal canal, as in boney spinal stenosis, spondylosis, and spondylolisthesis.
Nonweight-bearing bias-traction syndrome. The patient's symptoms are lessened when in nonweight-bearing positions, such as when lying down or in traction. Symptoms also lessen when spinal pressure is reduced by leaning on the upper extremities (using arm rests to unweight the trunk), by leaning the trunk against a support, or when in a pool. The condition is considered gravity sensitive because the symptoms worsen during standing, walking, running, coughing, or similar activities that increase spinal pressure. Often, traction and aquatic therapy are the only interventions that minimize symptoms during the acute phase.
Kinesthetic Awareness of Safe Postures and Effects of Movement
The patient is taught how to identify and assume the spinal position that is most comfortable and reduces the symptoms using pelvic tilts for lumbar positioning and head nods and chin tucks for cervical spine positioning. If necessary, corsets or cervical collars are used to provide support, and the patient is taught how to use passive positioning to help maintain the functional position during the acute stage (Box 15.6).
BOX 15.6 Examples of Passive Positioning of the Spine
Supine: Hook-lying flexes the lumbar spine; extended legs extends the lumbar spine. A pillow under the head flexes the neck; a small roll under the neck stabilizes a mild lordosis with the head neutral.
Prone: Use of a pillow under the abdomen flexes the lumbar spine; no pillow extends the spine. To maintain the cervical spine in neutral alignment without rotation, a split table or a small towel roll placed under the forehead provides space for the nose, so the patient does not turn the head.
Sitting: Usually causes spinal flexion, especially if the hips and knees are flexed. To emphasize flexion, the feet are propped up on a small footstool; to emphasize extension, a lumbar pillow or towel roll is placed in the low-back region. To unweight the spine, the arms are placed on an armrest, or a reclining chair is used.
Standing: Usually causes spinal extension; to emphasize flexion, one foot is placed on a small stool.
Muscle Performance: Deep Segmental Muscle Activation and Basic Stabilization
Whether the patient has a cervical or lumbar problem, as soon as tolerated, the patient is taught how to activate the deep segmental muscles.
Lumbar Region: Deep Segmental Muscle Activation
For the lumbar region, the "drawing-in" maneuver is used to activate the transversus abdominis and a gentle bulging contraction of the multifidus muscle. Facilitation techniques, which are described in detail in the 'Segmental Activation' section of Chapter 16, may be necessary.
Cervical Region: Deep Segmental Muscle Activation
For the patient with cervical pain, gentle head nods and slight flattening of the cervical lordosis in the supine position are used for activation of the longus colli and multifidus.
Once the patient learns to activate the segmental muscles, simple upper and lower extremity motions with the spine stabilized are added to the intervention to initiate training of the global stabilizers. Passive prepositioning is used if the patient is unable actively to maintain his or her functional position, as described in Box 15.6. For both cervical and lumbar problems, the patient is instructed first to do the drawing-in maneuver followed by gentle arm motions within a range that does not exacerbate symptoms. Leg motions require greater lumbopelvic control and are introduced if the patient is able to demonstrate pelvic control and the symptoms are not exacerbated with the movements. Suggestions for determining the exercise progressions are detailed in the 'Stabilization' section of Chapter 16.
Basic Functional Movements
The patient is taught to perform simple movements for ADLs while protecting the spine in the functional position. These movements include rolling from prone to supine and reverse, lying to sitting and reverse, sitting to standing and reverse, and walking. Descriptions of these maneuvers are in the 'Functional Activities' section of Chapter 16.
PRECAUTIONS: Review any special precautions for the condition with the patient. Condition-specific precautions are described in the remaining sections of this chapter.
General Guidelines for Managing Subacute Spinal Impairments: Controlled Motion Phase
When the signs and symptoms of the inflammatory process are under control and pain is no longer constant, the patient is progressed through a program of safe muscle endurance and strengthening exercises to prepare the tissue for functional activities and rehabilitation training. Functional activities that can be performed safely are resumed. Pain may still interfere with some daily activities, but it should no longer be constant. Poor neuromuscular control and stabilization, poor postural awareness and body mechanics, decreased flexibility and strength, and generalized deconditioning may be the underlying impairments at this stage. Intervention during this stage is critical, because either the patient feels good and tends to overdo activities and reinjures the tissues, or the patient is fearful and does not adequately resume safe movements, leading to further participations restrictions. Either extreme may slow down the recovery process.
Management guidelines for cervical and lumbar problems that require controlled motion interventions are summarized in Box 15.7. The specific techniques and progressions of intervention outlined here are described in detail in Chapter 16.
BOX 15.7 MANAGEMENT GUIDELINES—Subacute Spinal Problems/Controlled Motion Phase Impairments, Activity and Participation Restrictions (Functional Limitations)
Pain: only when excessive stress is placed on vulnerable tissues
Impaired posture/postural awareness
Impaired muscle performance: poor neuromuscular control of stabilizing muscles; decreased muscle endurance and strength
Inability to perform IADLs for extended periods of time
Poor body mechanics
|Plan of Care ||Intervention |
|1. Educate the patient in self-management and how to decrease episodes of pain. || |
1. Engage patient in all activities emphasizing safe movement and postures.
Home exercise program.
Ergonomic adaptation of work or home environment.
|2. Progress awareness and control of spinal alignment. ||2. Practice active spinal control in pain-free positions and with all exercises and activities. Practice posture correction. |
|3. Increase mobility in restricted muscles/joint/fascia/nerve. ||3. Joint mobilization/manipulation, neuromobilization, muscle inhibition, self-stretching. |
|4. Teach techniques to develop neuromuscular control, strength, and endurance. || |
4. Progress stabilization exercises; increase repetitions (emphasize muscle endurance).
Initiate extremity-strengthening exercises in conjunction with spinal stabilization.
|5. Develop cardiopulmonary endurance. ||5. Low to moderate intensity aerobic exercises; emphasize spinal bias. |
|6. Teach techniques of stress relief/relaxation. ||6. Relaxation exercises and postural stress relief. |
|7. Teach safe body mechanics and functional adaptations. ||7. Practice stable spine lifting, pushing/pulling, and reaching. Practice activities specific to desired outcome emphasizing spinal control, endurance, and timing. |
At this stage, use of modalities to modulate pain is not recommended. Emphasis is placed on increasing patient awareness of posture, strength, mobility, and spinal control and their relationship to modulating pain.
Kinesthetic training is progressed by using reinforcement techniques. Feed-forward control of the deep segmental musculature, active control of the spinal position, and correct posture are reinforced in a variety of ways until activation and control become habitual. Kinesthetic training overlaps the stabilization exercises.
Decreased flexibility in joints, muscles, and fascia may restrict the patient's ability to assume normal spinal alignment. Manual techniques and safe self-stretching techniques are used to increase muscle, joint, and connective tissue mobility.
Exercises are progressed with increased challenges for control, muscular endurance, and strength in the spinal stabilizing muscles; these exercises include activities that increase control and strength in the extremity musculature in conjunction with spinal stabilization. If a patient continues to display a flexion or extension bias, exercises are adapted to emphasize that particular bias and prevent stresses in the symptomproducing direction.
Stabilization exercises are used to emphasize movement and resistance to the extremities while maintaining control of the spinal position. Increasing the time and number of repetitions builds muscle endurance at each level of performance.
Wall slides, partial squats, partial lunges, pushing, and pulling against resistance are used to strengthen the extremities to prepare for lifting, reaching, pushing, and pulling activities.
When the patient learns effective spinal control with the stabilizing muscles in a variety of stabilization exercise routines, dynamic trunk and neck strengthening exercises, such as curl-ups, back extension, and cervical motions, are introduced. Care is taken to monitor symptoms and modify any activities that exacerbate the problem.
Aerobic capacity is usually compromised after injury. It is important to guide the patient in the initiation of or safe return to an aerobic conditioning program. It may be necessary to help the patient identify activities that do not exacerbate spinal symptoms.
Postural Stress Management and Relaxation Exercises
It is common that a patient's symptoms are exacerbated with sustained postural stresses such as sitting at a computer, talking on the phone (head tilted), or repetitive forward bending (shoe salesman); therefore, analysis of work, home, or recreational postures and activities is a necessary component of the patient's program. The patient is then advised about methods to correct the sustained or repetitive postural stresses. In addition, frequent changes of position and movement through the pain-free ROMs should be encouraged. It may be necessary to teach the patient how to consciously relax tension in muscles to relieve stress. Relaxation exercises are described in Chapter 14.
Once the patient has learned spinal control and stabilization and has developed adequate flexibility and strength for specific tasks, components of the task are incorporated into the exercise program and then into the patient's daily lifestyle. Safe body mechanics are included in all aspects of care.
General Guidelines for Managing Chronic Spinal Impairments: Return to Function Phase
Patients who have been treated through the acute and sub-acute phases of healing with appropriately graded exercises should have minimal structural or functional impairments that prevent or restrict daily activities. Individuals who must do heavy material handling (e.g., a manual laborer, firefighter, caregiver of small children or patients) or who participate in high-demand sports activities may require additional rehabilitative training to return safely to these high-demand activities and to avoid further injury. Impairments in strength, endurance, neuromuscular control, and skill are related to the functional goals of the individual. At this stage, conditioning and spinal control during high-intensity and repetitive activities are emphasized. Any underlying impairments that interfere with the desired outcomes must be remediated. Management guidelines for return to function are summarized in Box 15.8. Suggestions for progressing exercise intervention techniques from the subacute through chronic stages are described in Chapter 16.
BOX 15.8 MANAGEMENT GUIDELINES—Chronic Spinal Problems/Return to Function Phase Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations)
Pain: only when excessive stress is placed on vulnerable tissues in repetitive or sustained nature for prolonged periods
Poor neuromuscular control and endurance in high-intensity or destabilized situations
Flexibility and strength imbalances
Inability to perform high-intensity physical demands for extended periods of time
|Plan of Care ||Intervention |
|1. Emphasize spinal control in high-intensity and repetitive activities. ||1. Practice active spinal control in various transitional activities that challenge balance. |
|2. Increase mobility in restricted muscles/joints/fascia/nerve. ||2. Joint mobilization/manipulation, neuromobilization, muscle inhibition, self-stretching. |
|3. Improve muscle performance; dynamic trunk and extremity strength, coordination, and endurance. ||3. Progress dynamic trunk and extremity resistance exercises emphasizing functional goals. |
|4. Increase cardiopulmonary endurance. ||4. Progress intensity of aerobic exercises. |
|5. Emphasize habitual use of techniques of stress relief/relaxation and posture correction. ||5. Motions and postures to relieve stress. Apply any ergonomic changes to work/home environment. |
|6. Teach safe progression to high-level/high-intensity activities. ||6. Progressive practice using activity-specific training consistent with desired functional outcome, emphasizing spinal control, endurance, balance, agility, timing, and speed. |
|7. Teach healthy exercise habits for self-maintenance. ||7. Engage patient in all activities and educate as to benefits of maintaining fitness level and safe body mechanics. |
Management Guidelines: Nonweight-Bearing Bias
During examination, some patients do not respond to extension, flexion, or even mid-range spinal positions or motions due to the acuity of or mechanical stimuli from their condition. The person is often more comfortable lying down and may have partial or full relief with a traction test maneuver to the painful region of the spine.
For these patients, use of traction procedures or unweighting the body in a pool may be the interventions of choice until the symptoms stabilize.
Management of Acute Symptoms
Various references have reported the benefits of traction.19,131,147
Traction has the mechanical benefit of temporarily separating the vertebrae, causing mechanical sliding of the facet joints in the spine, and increasing the size of the intervertebral foramina. If done intermittently, this motion may help reduce circulatory congestion and relieve pressure on the dura, blood vessels, and nerve roots in the intervertebral foramina. Improving circulation also may help decrease the concentration of noxious chemical irritants due to swelling and inflammation.
There may be a neurophysiological response via stimulation of the mechanoreceptors that may modulate the transmission of nociceptive stimuli at the spinal cord or brain stem level.
Various unloading devices or body weight support systems may be used, such as partially suspending the patient in a harness while he or she performs ambulation on a treadmill or gentle extremity exercises.
If a person is not fearful of being in a pool, supporting the individual with a buoyant life belt in deep water reduces the effects of gravity on the lumbar spine. If symptoms are reduced, it may be possible to begin and progress gentle stabilization exercises in this buoyant environment to meet some of the goals during the acute and subacute phases. Exercises can also be progressed by using the properties of water for resistance and stretching (see description of aquatic exercises in Chapter 9).
As healing occurs, the patient should begin to tolerate weight bearing. After re-examination and assessment, identify the impairments and activity and participation restrictions. If a bias toward flexion or extension is determined, or if there are areas of hyper- or hypomobility, plan the interventions accordingly.
Management Guidelines: Extension Bias
Patients with an extension bias often assume a flexed posture or a flexed posture with lateral deviation of the trunk or neck, but during the examination, sustained or repetitive extension maneuvers reduce or relieve their symptoms. These patients would benefit from early interventions that emphasize extension of the involved segments. The impairments may be due to a contained intervertebral disc lesion, fluid stasis, a flexion injury, or muscle imbalances from a faulty flexed posture. McKenzie101,102,103 developed a method of categorizing these patients based on the extent of their pain and/or neurological symptoms. He also described the phenomena of peripheralization and centralization that accompany an expanding and receding lesion, frequently attributed to intervertebral disc lesions (see Fig. 15.2).
Many of the techniques that were originally described by McKenzie101,102,103 to manage a patient with an acute disc lesion have been found to be beneficial in the management of patients who have a cluster of signs and symptoms that categorize them into the extension bias (extension syndrome) category.46,48,93,142
Because patients with signs and symptoms of a bulging intervertebral disc often fit into the "extension bias" category, a brief discussion of the response of the intervertebral disc is presented here.
Effects of Postural Changes on Intervertebral Disc Pressure
Relative changes in posture and activities affect intradiscal pressure. When compared to the level of pressure when standing, intradiscal pressure is least when lying supine, increases by almost 50% while sitting with hips and knees flexed, and almost doubles if leaning forward while sitting.147 Sitting with a back rest inclination of 120° and lumbar support 5 cm in depth provides the lowest load to the disc while sitting.7 Therefore, sitting with the hips and knees flexed or leaning forward should be avoided when there is an acute disc lesion. If sitting is necessary, there should be support for the lumbar spine by reclining the trunk 120°.
Effects of Bed Rest on the Intervertebral Disc
When a person is lying down, compression forces to the disc are reduced; and with time, the nucleus potentially can absorb more water to equalize pressures (imbibition). When lying down with the spine in flexion, the imbibed fluid accumulates posteriorly in the disc where there is greater space. Then, upon rising, body weight compresses the disc with the increased fluid, and intradiscal pressure greatly increases. The pain or symptoms from a disc protrusion are accentuated. To avoid exacerbating symptoms, absolute bed rest during the acute phase should be avoided. Bed rest during the first 2 days (when symptoms are highly irritable) may be needed to promote early healing, but it should be interspersed with short intervals of standing, walking, and appropriately controlled movement.161
Effects of Traction on the Intervertebral Disc
Traction may relieve symptoms from a disc protrusion. It is proposed that separating the vertebral bodies may have the effect of placing tension on the annular fibers and posterior longitudinal ligament, thus have a flattening effect on the bulge; or it may decrease the intradiscal pressure.147 If traction relieves symptoms, the time of application must be short because with the reduced pressure fluid imbibition may occur to equalize the pressure. Then, when the traction is released, the pressure increases and symptoms are exacerbated.
Effects of Flexion and Extension on the Intervertebral Disc and Fluid Stasis
Rest in a slightly forward-bent position often lessens pain because of the space potential for the nucleus pulposus of the intervertebral disc. The patient may also deviate laterally to minimize pressure against a nerve root. Movement into extension initially causes increased symptoms. With acute disc lesions in which there is protective lateral shifting and lumbar flexion, techniques that cause lateral shifting of the spine opposite to the deviation followed by passive spinal extension (sustained or repetitive) to compress the protrusion mechanically have been found to relieve the clinical signs and symptoms in many patients.88,102
Patients experiencing pain due to fluid stasis after being in a sustained flexed posture also experience relief with movement into extension.
FOCUS ON EVIDENCE
In a study of 20 subjects with low back pain who were candidates for extension-based treatment, those who experienced an immediate decrease in pain intensity (N = 10) of at least 2/10 after treatment (posterior to anterior mobilization followed by prone press-ups) demonstrated a mean increase in diffusion coefficient of 4.2% of the nuclear region of the L5-S1 IV disc measured by MRI. Those who did not experience pain reduction (N=10) did not have a change in diffusion (mean decrease of 1.6% (P<.005).11a
Effects of Isometric and Dynamic Exercise
Isometric activities (resisted pelvic tilt exercises, straining, Valsalva maneuver) and active back flexion or extension exercises increase intradiscal pressures above normal. They, therefore, must be avoided during the acute stage of a disc lesion. Strong muscle contractions also exacerbate symptoms if a muscle has been injured. Therefore, active and resistive extension exercises are avoided during the acute stage.
Effects of Muscle Guarding
Reflex muscle guarding or splinting often accompanies an acute disc lesion and adds to the compressive forces on the disc. Modalities and gentle oscillatory traction to the spine may help decrease the splinting.
Indications, Precautions, and Contraindications for Interventions: Extension Approach
Indications. Extension is used if pain and/or neurological symptoms centralize (decrease or move more proximally) during repeated extension testing maneuvers and peripheralize (worsen) during flexion.82,101 Extension is also indicated for flexed postural dysfunctions with limited range into extension. If no test movements decrease the symptoms, this mechanical approach to treatment should not be used.
PRECAUTION: A patient with acute pain in the spinal region that is not influenced by changing the patient's position or by movement must be screened by a physician for signs of serious pathology.
CONTRAINDICATIONS: When there is an acute disc lesion, any form of exercise or activity that increases intradiscal pressure, such as the Valsalva maneuver, active trunk flexion, or trunk rotation, is contraindicated during the protection phase of treatment. Any movement that peripheralizes the symptoms signals a movement that is contraindicated during the acute and early subacute period of treatment. Peripheralization with extension motions may indicate stenosis, a large lateral disc protrusion, or pathology in a posterior element141 (Box 15.9).
BOX 15.9 Contraindications to Specific Spinal Movements
Extension of the spine is contraindicated64,65:
When no position or movement decreases or centralizes the described pain
When saddle anesthesia and/or bladder weakness is present (could indicate spinal cord or cauda equina lesion)
When a patient is in such extreme pain that he or she rigidly holds the body immobile with any attempted correction
Flexion of the spine should be avoided:
Interventions Using an Extension Approach in the Lumbar Spine
Management of Acute Symptoms
If symptoms are severe, bed rest is indicated with short periods of walking at regular intervals. Walking usually promotes lumbar extension and stimulates fluid mechanics to help reduce swelling in the disc or connective tissues. If the patient cannot stand upright, he or she should use crutches to help relieve the increased pressure of the forwardbent posture.82
If repeated flexion test movements increase the symptoms and if repeated extension test movements decrease or centralize the symptoms, all flexion activities should be avoided during the early phases of intervention. Treatment begins with the following maneuvers.
Patient position and procedure: Prone. If the flexion posture is severe, place pillows under the abdomen for support. Gradually increase the amount of extension by removing the pillows and then progress by having the patient prop himself or herself up on the elbows, allowing the pelvis to sag (Fig. 15.4 A). When propping, pillows placed under the thorax help take strain off the shoulders. Wait 5 to 10 minutes between each increment of extension to allow reduction of the water content and the size of the bulge. There should be an accompanying centralization of or decrease in symptoms. Progress to having the patient prop himself or herself up on the hands, allowing the pelvis to sag (Fig. 15.4 B).
Lumbar extension is accomplished (A) by having the patient prop up on the elbows and (B) by propping on hands and allowing the pelvis to sag.
If the sustained position of prone propping is not well tolerated, have the patient perform passive lumbar extension intermittently by repeating the prone press-ups (same end position as Fig. 15.4 B) rather than just propping up.
PRECAUTION: Carefully monitor the patient's symptoms. They should lessen peripherally (i.e., decreased foot and leg symptoms or decreased thigh and buttock symptoms) but may increase (centralize) in the low back. If the symptoms progress down the lower extremity (peripheralize), immediately stop the exercises and reassess.102
If the patient has lateral shifting of the spine (Fig. 15.5), extension alone cannot reduce a nuclear protrusion of the disc until the shift is corrected. Once the shift is corrected, the patient must extend (as described above) to maintain the correction. Methods to correct the shift in various positions include the following.
Patient with lateral shift of the thoracic cage toward the right. The pelvis is shifted toward the left.
Patient position and procedure: Standing with flexed elbow against the side of the deviated rib cage. Stand on the side to which the thorax is shifted and place your shoulder against the patient's elbow. Then wrap your arms around the patient's pelvis on the opposite side and simultaneously pull the pelvis toward you while pushing the patient's thorax away (Fig. 15.6). This is a gradual maneuver. Continue with the lateral shifting if centralization of the symptoms occurs. If there is overcorrection, the pain and lateral shift may move to the contralateral side, which is corrected by shifting the thorax back. The purpose is to centralize the pain and correct the lateral shift. Once the shift is corrected, immediately have the patient backward-bend (Fig. 15.7). Again, allow time. Progress to passive extension with prone propping and prone press-ups as previously described.
A lateral gliding technique used to correct a lateral shift of the thorax is applied against the patient's elbow and thoracic cage as the pelvis is pulled in the opposite direction.
Patient position and procedure: Side-lying on the side to which the thorax is shifted. Place a small pillow or towel roll under the thorax. The patient remains in this position until the pain centralizes; he or she then rolls prone and begins passive extension with prone propping and prone press-ups.
Patient position and procedure: Prone. Attempt to side-glide the thorax and pelvis toward the midline with manual pressure. The forces are in equal and opposite directions. Once the symptoms centralize, instruct the patient to begin passive extension with prone propping and prone press-ups.
Teach self-correction of the lateral shift. The patient places the hand on the side of the shifted rib cage on the lateral aspect of the rib cage and places the other hand over the crest of the opposite ilium and then gradually pushes these regions toward the midline and holds (Fig. 15.8).
Self-correction of a lateral shift.
Help the patient recognize what positions and motions increase or decrease the pain or other symptoms by performing them under supervision.
Instruct the patient to repeat the extension activities frequently, with lateral shift correction if necessary, during the first couple of days. The more severe the symptoms the more frequently the extension exercises should be completed. Typically they should be performed immediately upon waking up and after periods of prolonged sitting and/or bending.
Caution the patient to stop the activity immediately if the pain worsens or peripheralizes during exercises.
Instruct the patient to maintain an extended posture with passive support while the lesion is healing. For example, have the patient use a towel roll or lumbar pillow while sitting. This is especially important when riding in a car or sitting in a soft chair. When going to bed, have the patient pin a towel, folded lengthwise four times, around the waist.
Instruct the patient to avoid flexion activities, lifting, or any other functions that increase intradiscal pressure while symptoms are acute.
Teach safe movement patterns to protect the back as described in the guidelines for treating acute spinal problems (see Box 15.5).
Traction may be tolerated by the patient during the acute stage and has the benefit of widening the disc space and possibly reducing the nuclear protrusion by decreasing the pressure on the disc or by placing tension on the posterior longitudinal ligament.147
Time of the traction should be short; osmotic forces soon equalize. However, upon release of the traction force, there could be an increase in disc pressure, leading to increased pain. Use less than 15 minutes of intermittent traction or less than 10 minutes of sustained traction.
High poundage; more than half the patient's body weight is necessary for separating the lumbar vertebrae.
If there is complete relief initially, often there is an exacerbation of symptoms later.
Grades I through IV joint mobilization/manipulation may be utilized preceding the prone press ups, but high-velocity thrust should not be performed as this may promote inflammation at the segment. High-velocity thrusts also require a rotation component, and this may place further stress on the disc.
Kinesthetic Training, Stabilization, and Basic Functional Activities
Once the patient learns to control the symptoms the following should be emphasized.
Teach simple spinal movements in pain-free ranges using gentle pelvic tilts. The patient is taught to be aware of how far forward and backward he or she can rock the pelvis and move the spine without increasing the symptoms. The pelvic rocking is done in supine, sitting, hand-knee all-fours (quadruped), prone-lying, side-lying, and standing positions. It is important to stay within the patient's ability to control the symptoms. Instruct the patient to finish all exercise routines with the pelvis tilted anteriorly and the spine in extension.
Teach the patient basic stabilization techniques utilizing the core trunk muscles while maintaining control of the extended spinal position and performing simple extremity motions. It is important to caution against holding the breath and causing the Valsalva maneuver, which would excessively increase the intradiscal pressure.
Encourage activities, such as walking or swimming, within the tolerance of the individual.
Initiate passive, straight-leg raising with intermittent dorsiflexion and plantarflexion to maintain mobility in the nerve roots of the lumbar spine.
Management When Acute Symptoms Have Stabilized
Improvement is noted with loss of spinal deformity, increased motion in the back, and negative dural mobility signs.82 Loss of back pain with an increase in true neurological signs is an indication of worsening. The patient is tested to determine that the symptoms have stabilized; this is accomplished by performing repeated flexion and extension tests with the patient standing and then lying supine and prone as done initially. The tests may be positive for structural impairments (restricted motion, weakness, tension), but should not cause peripheralization of the symptoms, as when the condition was acute.102
The emphases during this stage are recovery of function, development of a healthy back care plan, and teaching the patient how to prevent recurrences (see Boxes 15.6 and 7). The pain from adaptive shortening decreases as normal flexibility, neural mobility, strength, and endurance are restored.
In addition to general exercise instruction, teach the patient these principles.
Following any flexion exercises, perform extension exercises, such as prone press-ups or standing back extension (see Figs. 15.4 and 15.7).
If being in a prolonged flexed posture is necessary, interrupt the flexion with backward bending at least once every hour. Also, perform intermittent pelvic tilts.
If symptoms of a protrusion develop and are felt, immediately perform press-ups in the prone position, anterior pelvic tilts in the quadruped position, or backward bending while standing to prevent progression of the symptoms.
Interventions to Manage a Disc Lesion in the Cervical Spine
Disc lesions in the cervical spine are less common than in the lumbar spine. Herniated discs are most common between the C6 and C7 vertebrae; this is likely due to the increased mobility at this transitional section between the cervical lordosis to the thoracic kyphosis. It may also be the result of degeneration, osteophytes, or poor posture. Patients may present with peripheral neuropathy and forward-head posture without a diagnosis of disc pathology. Symptoms increase with activities and postures that increase flexion in the lower cervical and upper thoracic spine and decrease with extension in that region (axial extension or neck retraction).1
Conservative management is similar to that in the lumbar spine and follows the same principles described in the previous section. Medical management includes pharmacological pain and inflammation control measures. Often disc extrusions are an indication for surgery because of potential compromise of the spinal canal and pressure on the spinal cord.144 These procedures are described in the next section.
Passive Axial Extension (Cervical Retraction)
Patient position and procedure: Begin with the patient supine, with no pillow under the head or neck. Gently nod the patient's head, and allow the neck to flatten against the treatment table. If the neck is deviated or rotated to one side, moving the head and neck back toward the midline must be done first. This may require gentle, progressive positioning and may take 10 to 20 minutes to accomplish.
Progression: Progress the retraction to hyperextension of the cervical spine and then progress to rotation. Use caution and carefully monitor the signs and symptoms; do not progress if symptoms peripheralize down the arm.
Teach the patient to retract his or her head and neck passively in the sitting position. The patient may gently push against the chin (caution not to push so hard as to cause joint compression of the temporomandibular joint) to direct the motion. This technique has been shown to improve the H-reflex amplitude and may be useful for improving mobility and decreasing symptoms of radiculopathy by decompressing nerve roots in the lower cervical spine.1
Cervical traction may relieve the patient's symptoms. As described for lumbar traction, during the acute phase, sustained traction should be no longer than 10 minutes and intermittent traction no longer than 15 minutes in duration. The dosage is at an intensity that causes vertebral separation (at least 15 lb).
Kinesthetic Training for Posture Correction
Instruct the patient in safe mechanics for maintaining the head position. During the acute phase, the patient may need to wear a cervical collar to immobilize the spine. It is important to help the patient identify the posture that centralizes the symptoms and to adjust the collar to maintain that position.
Progression as Symptoms Stabilize
Follow the guidelines described in Boxes 15.5 and 15.7. Faulty cervical, thoracic, and scapular posture may be present. Emphasize kinesthetic training for postural awareness, stabilization exercises for postural control with emphasis on the scapular and shoulder muscles, environmental adaptations to reduce postural stresses, and functional activities with safe spinal mechanics.
FOCUS ON EVIDENCE
Kjellman and Oberg84 randomly placed 77 people with neck pain into one of the following three groups: general exercise, McKenzie extension exercise, and a control group (ultrasound and education). Outcome measures were pain intensity and the Neck Disability Index. After 12 months, all groups showed significant improvement with no significant difference between the three groups, with nearly 70% of patients reporting they were better or completely restored. The authors did note, though, that in the short term (during the first 3 weeks of treatment), those in the extension exercise group had more favorable response to treatment than the general exercise group or the control group, and there was a tendency that those in the extension exercise group used the health-care system less frequently during the 6 to 12 month period. Analysis showed significant improvement between the extension exercise group and control group at 3 weeks and at 6 months (P<0.05).
Disc Lesions: Surgery and Postoperative Management
Patients with upper or lower extremity radiculopathy, caused by nerve root irritation and who have failed conservative measures including physical therapy, medications, and steroid injections may be appropriate surgical candidates.20,21,22,50,85,97,123,132,159
The two most common surgical procedures in the spine are laminectomy and fusion of one of more vertebrae.98
Laminectomy. A laminectomy is the removal of the lamina. A partial or hemi-laminectomy is a removal of only part of the lamina; a complete laminectomy is the excision of the entire lamina, the spinous process, and the ligamentum flavum that attached to the lamina. The primary disadvantage to a complete laminectomy is that the surgical segment loses its anatomical stabilization.21,22,65 A laminectomy is typically indicated over a fusion in patients with a small unilateral disc protrusion. The benefits of a laminectomy are that the patients retain segmental mobility while experiencing symptom relief.
Fusions. Fusions are indicated when the patient presents with axial pain combined with instability, severe arthritic degenerative changes, or peripheral pain that is not controlled.20,22,50,63,85,97,123,132,159 The advantages of a spinal fusion are that it reduces or eliminates segmental motion, reduces mechanical stress at the degenerated disc area, and reduces the incidence of additional herniations at the affected disc site.159 However, effects of a fusion may expedite the degenerative processes, create a hypermobility at adjacent spinal segments, and alter overall spinal mechanics.12,41,65
Anterior cervical disc fusion. Anterior cervical disc fusion (ACDF) involves a horizontal incision at the level(s) of the cervical vertebrae that are to be fused. Both the platysma and longus coli muscles are interrupted during this procedure. Once the disc is excised, the adjacent vertebrae are then internally fixated with a single unilateral plate and screws attaching directly to the vertebral bodies. Although complications are rare, they can include sore throat, hoarseness, and difficulty swallowing.53 Medical complications involving the heart, lungs, and other organs affect approximately 5% of surgical patients following ACDF.98 Neurological or more serious complications, including myelopathy, radiculomyelopathy, and recurrent laryngeal nerve palsy, have been reported as ranging from 1% to 4% of the post-surgical population.13,20,45
Pain has been reported to significantly decrease following ACDF.50,85,123 Good to excellent outcomes have been reported as high as 92%.65
Transforaminal lumbar interbody fusion. Transforaminal lumbar interbody fusion (TLIF) involves a vertical incision centrally along the posterior spine.63 The paraspinals muscles, including the multifidi, are refracted prior to the removal of the lamina, spinous process, and ligamentum flavum. The vertebrae are fused together using bone from the facetetomy and autologous bone from the iliac crest.63 Complications, occurring in 2% to 4% of patients, include infection, epidural bleeding, neural injury, postsurgical instability, epidural fibrosis, and arachnoiditis.12,58,132
Good overall outcomes of approximately 80% have been reported.8,58 Berg and associates12 identified that 84% of people reported improvement and/or complete resolution of pain at 1 year postoperatively and 86% at 2 years. The authors also reported that 71% of people returned to work after one year.12 In a similar study, Schizas and colleagues148 reported a 2.2 point decrease in pain on the visual analogue scale and a 27 point improvement in the Oswestry Disability Index at 24 months postoperative.
Laminectomy. Laminectomies can be performed in either the lumbar or cervical spine regions. Both involve a posterior approach and are performed similarly to a posterior fusion with the exception that the vertebrae are not internally fixated to each other. The recovery time and return to work time are usually much quicker as compared with a fusion. However, similar rehabilitation guidelines are followed as described in the next section.
Postoperative management is similar for all of these surgical procedures.
Patient education. Educate the patient on the expectations of the surgeon, the surgical procedure, and the rehabilitation involved in the process. Also, instruct the patient on any restrictions as detailed by the surgeon. These restrictions typically include no heavy lifting (> 10 pounds) for up to 3 months. Limitations in active motions may also be imposed depending on the surgeon's preference and type of procedure.
Wound management and pain control. Teach the patient to look for signs of inflammation such as redness, swelling, or non-closure of the wound.
Bed mobility. The patient must relearn how to perform bed mobility as they may be wearing a spinal orthotic that prevents normal movement.
Bracing. To promote healing, patients who have undergone either an ACDF or TLIF are typically placed in a Philadelphia collar then a soft collar or a chairback brace, respectively, for up to 3 months. The patient may be allowed to remove the brace to shower but must immediately don the orthotic upon getting dressed.
Exercises. Encourage walking and gentle exercises that can be completed in the supine position. Include A-AROM or AROM heel slides, short-arc quads, quad and gluteal isometrics, and ankle pumps. Patients who have undergone a laminectomy are instructed to avoid excessive extension due to the weakened boney neural arch.
CONTRAINDICATIONS: Patients are to avoid a shower or getting the incision wet until it is completely closed. This is usually 1 to 2 weeks following surgery. As described above, the patient is instructed to follow the surgeon's guidelines regarding limitations with movement and lifting.
Moderate and Minimum Protection Phases
Scar tissue mobilization. After the incision site is healed, initiate scar mobilization to improve connective tissue mobility and decrease pain at the surgical site.
Progressive stretching and joint mobilization/manipulation of restricted tissue. Gentle (grade I to II) joint techniques at adjacent segments are indicated for pain modulation and improved ROM.
Initiate segmental and progress to global stabilization exercises to patient tolerance.64a
Address patient goals directed at minimizing specific activity restrictions and impairments.
Begin with single plane exercises and progress complexity as patient tolerates.
Gait training. Once the patient is allowed to ambulate, an assistive device is usually indicated to facilitate an erect posture and unload some of the stress to the surgical area.
The patient must continue to follow the surgeon's contraindications to promote optimal healing.
Joint manipulations at the level(s) of the fusion are contraindicated.
Extension exercises, including prone press-up, are contraindicated in patients who have undergone a laminectomy.
FOCUS ON EVIDENCE
A Cochrane Review of randomized, controlled studies of rehabilitation programs following lumbar disc surgery concluded that for exercise programs that started 4 to 6 weeks after surgery there was less short-term pain and disability compared to patients who received no treatment. The review also indicated high-intensity programs resulted in less short-term pain and disability than low-intensity programs, and that home exercise programs were as effective as supervised programs. None of the studies reviewed reported an increase in the reoperation rate.120
Management Guidelines: Flexion Bias
Patients may present with a flexed posture and be unable to extend because of increased neurological symptoms and decreased mobility; these patients would benefit from early interventions that emphasize flexion of the involved segments to relieve symptoms. The patients may have a medical diagnosis of spondylosis or spinal stenosis (central or lateral), an extension load injury, or capsular impingement or swollen facet joints, so symptoms increase with extension. The flexed position reduces or relieves the symptoms.
Physical therapy interventions focus on increasing the diameter of the foramen and minimizing nerve root irritation.
Effect of position. Flexion widens the intervertebral foramina, whereas extension decreases the size of the foramina. Any compromise of the foraminal opening, such as encroachment from boney spurs or lipping or swollen tissue, reduces the space. The patient may describe intermittent nerve root symptoms (intermittent numbness or tingling) whenever the involved segment extends, indicating mechanical compression. Constant nerve root symptoms could be caused by inflammation and swollen tissue.
Effect of traction. Traction has been demonstrated to widen the intervertebral foramina. Positioning the spine in flexion prior to the application of traction provides the greatest increased space.19,93,131 Positional traction, in which the patient is placed in side bending away from the side or direction of pain and rotation toward the pain, may also be beneficial to increase the diameter of the lateral foramen.
Effect of trauma and repetitive irritation. Swelling in the facet joints from macrotrauma or microtrauma leads to a compromised foraminal space. With degeneration and increased mobility in a spinal segment, instability could be the cause of repetitive microtrauma, leading to swelling and pain.
Effect of meniscoid tissue. The meniscoid tissue of the joint capsule may become impinged with sudden movements. This blocks specific movements, such as extension and side bending to the involved side. Manipulation and traction usually relieve the symptoms.
Indications and Contraindications for Intervention: Flexion Approach
Indications. Flexion is used if neurological and/or pain symptoms are eased with flexion and worsened with extension positions or motions.
CONTRAINDICATIONS: Extension and extension with rotation positions, motions, and exercises are contraindicated if neurological symptoms or pain worsen with these motions. Flexion exercises are contraindicated if neurological or pain symptoms peripheralize with flexion or repeated flexion maneuvers (see Box 15.9).
Techniques Utilizing a Flexion Approach
In general, spinal flexion postures and exercises are taught following the guidelines described in Boxes 15.5, 15.7, and 15.8. The following suggestions should also be considered for special conditions.
Management of Acute Symptoms
With acute joint symptoms, a cervical collar or lumbar corset may help provide rest to the inflamed or swollen facet joints or provide caution to others, so they avoid inadvertently provoking spinal movement. It is important to discontinue the use of such devices as the acute symptoms decrease, so the muscles can learn dynamic control and avoid dependence.
Support is also beneficial in the management of patients with RA or other disorders associated with hypermobility or instability.
Functional Position for Comfort
For flexion bias in the lumbar spine, the position is usually with the hips and knees flexed so the lumbar spine flexes.
In the cervical spine, the position is toward axial extension (upper cervical flexion) with some flexion also in the lower cervical region.
If there are neurological signs, the position provides maximal opening of the intervertebral foramina to minimize impingement of the nerve root.
Gentle intermittent joint distraction and gliding techniques may inhibit painful muscle responses and provide synovial fluid movement in the joint for healing.
Dosages must be very gentle (grade I or II) to avoid stretching the capsules and are best applied with manual techniques during the acute stage.
With spondylosis or stenosis, if a patient does not have signs of acute joint inflammation but does have signs of nerve root irritation, stronger traction forces may be beneficial to cause opening of the intervertebral foramina, which helps relieve the pressure.
CONTRAINDICATION: If a patient has RA, traction and joint mobilizations/manipulations in the spine are potentially dangerous because of ligamentous necrosis and vertebral instability; therefore, they should not be performed.106
Correction of Lateral Shift
If the patient has a lateral shift of the thoracic region along with symptom relief when in flexion, he or she may be taught self-correction.
Patient position and procedure: Standing with the leg opposite the shift on a chair so the hip is in about 90° of flexion. The leg on the side of the lateral shift is kept extended. Have the patient then flex the trunk onto the raised thigh and apply pressure by pulling on the ankle (Fig. 15.9).
Self-correction of a lateral shift when there is deviation of the trunk as it flexes.
Correction of Meniscoid Impingements
If there is entrapped synovial or meniscoid tissue in a facet joint that blocks motion into extension, release of the trapped meniscoid relieves the pain and the accompanying muscle guarding. The joint surfaces need to be separated and the joint capsules made taut.15 General techniques include traction and manipulation.
Traction to the spine may be applied manually or mechanically. The patient also can be taught self-traction and positional traction techniques. Traction applied longitudinally along the axis of the spine has the effect of sliding the facets' joint surfaces and thus placing tension on the facet capsules. Traction with contralateral side bending and rotation of the spine has the effect of distracting the facet joint surfaces as well as placing tension on the capsules.
Techniques of manual traction, self-traction, positional traction with rotation and manipulations are described in the stretching section of Chapter 16.
Management When Acute Symptoms Have Stabilized
General guidelines for subacute and chronic spinal problems are summarized in Boxes 15.7 and 15.8. Specific emphasis when treating patients with mobility impairments due to hypomobile or hypermobile facet joints should include the following.
Hypomobile joints require stretching but not if the techniques stress a hypermobile region. Traction techniques may be effective if the hypermobile region is stabilized during stretching. For those trained in joint mobilization/manipulation techniques, these techniques are effective for selective facet joint stretching and have been found to be an effective part of a total treatment approach when there is instability in specific areas and restricted mobility in neighboring facet joints.119 Emphasis is on developing dynamic stability through muscle control in the hypermobile regions while gaining mobility in the restricted regions.
Strength and flexibility of the trunk, hip, and shoulder girdle musculature require selective stretching and strengthening. These are summarized in Box 15.10.
If there are boney changes and osteophytic spurs, the patient should avoid postures and activities of hyperextension, such as reaching or looking overhead for prolonged periods of time. Adaptations in the environment might include using a stepstool so reaching is at shoulder level. Postures and motions emphasizing flexion of the spine that increase the size of the intervertebral foramina are usually preferred.
For patients with RA, emphasis is on stabilization and control. Because of the potential instabilities from necrotic tissue and bone erosion, subluxations and dislocations may cause damage to the spinal cord or vascular supply and can be extremely debilitating or life-threatening.
BOX 15.10 Muscle Imbalances Common with Flexion Bias (Syndrome) Lumbopelvic Region
Muscle weakness: Cervicothoracic Region
FOCUS ON EVIDENCE
Cleland and associates27 identified 96 consecutive patients with cervical radiculopathy. Patients had a 90% success rate using an intervention manual therapy, traction, and deep neck flexor strengthening exercises if they met the following criteria: <54 years old; dominant hand not affected; looking down does not worsen the symptoms; and muscle energy and/or thrust, traction, and deep neck flexor muscle strengthening used ≥50% of the time during PT sessions.
Tseng154 followed 100 patients with neck pain and identified 6 variables for patient success with manipulation. The authors concluded that if the patients met four of the following criteria their chance for success using cervical manipulation was 89%. The variables are: initial Neck Disability index <11.5; bilateral involvement pattern; not performing sedentary work >5 hours each day; feeling better while moving neck; did not feel worse with neck extension; and diagnosis of spondylosis without radiculopathy.
Raney and colleagues 136 applied mechanical traction to 68 patients with neck pain for 15 minutes each session. Mechanical traction was found to be 90% successful in 90% of the patients if they met 4 of the 5 following criteria: (1) patient reported peripheralization with C4–7 mobility testing; (2) patient had a positive abduction sign; (3) patient was age 55 years or older; (4) patient returned a positive median nerve tension test; and (5) patient experienced relief of symptoms with manual distraction.
Management Guidelines: Stabilization
Patients with segmental instability—including hypermobility; ligamentous laxity; diagnoses such as spondylolysis, spondylolisthesis, or poor neuromuscular control of the deep segmental and global stabilizing musculature—require interventions that improve stability. Some of the patients may have a history of trauma, repeated manipulations, or early signs of spondylosis. Mobility testing of the spinal segments reveals increased mobility at one or more segments. There may be decreased activity in the stabilizing musculature, particularly in response to postural perturbations, and there may be faulty respiratory patterns. (Additional information on spondylolisthesis is in the final section of this chapter.)
Identification of Clinical Instability
Stress radiographs are typically used by the medical profession to identify instability. Those with more than 4 mm of translation or 10° of rotation are considered candidates for surgery.47 Radiographs can identify problems only in the passive structures. To identify impairments in the musculature and the ability to control movement, techniques have been developed that specifically address core muscle activation and endurance and global muscle stabilization. The following may be used.
Quality of movement. Observe spinal ROM (standing) and note if there is a catch or aberrant movement. Patients may demonstrate difficulty moving smoothly in the mid-ranges as well as a shifting or fluctuation in movement.49
Control of deep segmental musculature. In the lumbar region, it is possible to palpate the transversus abdominis and multifidus muscles while the patient attempts to contract them. Devices to measure activation, such as using a biopressure feedback unit or ultrasound imaging, have been developed for both research and clinical usage74 (see next section under 'Principles of Management' as well as Chapter 16).
Control of the global musculature. Several protocols have been developed to test the stabilizing function of the global musculature.51,62,137 They primarily challenge the isometric holding capability of the anterior, posterior, and lateral trunk musculature under various loads.
Braces or corsets may be necessary for external support to provide stability and reduce pain.47 Ideally, these devices should be used in conjunction with training the deep segmental musculature for dynamic control.
Deep Segmental Muscle Activation
Activation of segmental musculature may not be automatic in patients with pain or instability. In addition to verbal and tactile cues, techniques used to instruct patients include use of a biofeedback pressure cuff (Chattanooga®) and ultrasound imaging. Ultrasound imaging is primarily used in research settings because of the cost of the units. The pressure cuff has been shown to have clinical relevance in providing immediate feedback to patients.74 Use of the cuff for testing and instruction in deep segmental muscle activation of the cervical and lumbar regions is described in detail in the Muscle Performance section of Chapter 16.
Once the patient learns to activate the segmental muscles, emphasis is placed on sustaining the contraction over a period of time and on increasing the repetitions of the static hold to reinforce the postural function. These contractions are of low-intensity to minimize the compressive activity of the global muscles.55
Initially, the patient is taught to find and maintain a neutral spinal position using pelvic tilts (mid-range). The patient is then instructed in the "drawing-in maneuver" to activate the transversus abdominis, and he or she learns to contract the multifidus by bulging out the muscle. Gentle co-activation of the muscles of the perineum facilitates contraction of these segmental muscles.114
FOCUS ON EVIDENCE
Hicks and associates66 determined that the patients most likely to benefit from stabilization exercises were those with lumbar segmental instability who met three or more of the following criteria: positive prone instability test, aberrant motions during lumbar ROM, average straight-leg raise less than 91°, and age less than 40 years.
The patient is taught to activate the segmental musculature with gentle capital nodding and slight flattening of the cervical lordosis.55
Progression of Stabilization Exercises
Progressing from segmental muscle activation to general stabilization exercises using the global musculature emphasizes cervical and pelvic control while superimposing extremity motions. Included are weight-bearing activities, such as wall slides, partial lunges, and partial squats, with emphasis on the "drawing-in" maneuver and spinal control in the neutral spinal position while doing the activities.
Functional activities are incorporated into the stabilization exercise routines. The patient is encouraged to activate the segmental musculature consciously and maintain a neutral spinal position until it becomes habitual.
Management Guidelines: Mobilization/Manipulation
NOTE: The terms manipulation and mobilization are currently being used interchangeably, with a trend toward using the term manipulation (see Chapter 5). The authors of this chapter are using manipulation to mean graded oscillation techniques and high-velocity thrust (HVT) to mean high-velocity, small-amplitude motion performed at the end of the pathological limit of the joint. When describing or documenting manipulation techniques used, the clinician is reminded to define the intensity (grade I–IV or HVT) as well as spinal level (target), direction of force application, and patient position.
Some patients benefit from spinal manipulation during the early stages of intervention.25,28 Hypomobile spinal segments may add to stress of hypermobile segments and require a combined approach of manipulation as well as stabilization exercises.75,119 Manipulation techniques for the cervical, thoracic, and lumbar spines are described in Chapter 16.
Following determination of a hypomobile segment in the lumbar spine, perform the general manipulation (using the lumbar roll technique) up to two times followed by instruction in ROM exercises. This is repeated for two sessions, after which the patient is instructed in stabilization exercises and progressed through treatment as summarized in Boxes 15.7 and 15.8.
The lumbopelvic technique used in validation studies24,25 as well as an alternate technique28 are described in Chapter 16. The traction procedures described in the nonweight-bearing section earlier in this chapter may also be beneficial.
FOCUS ON EVIDENCE
In a randomized controlled trial of 71 subjects with low back pain, Flynn and associates44 determined that patients most likely to benefit from spinal manipulation prior to stabilization exercises were those who met four of five of the following criteria: symptom duration less than 16 days; no symptoms distal to the knee; score less than 19 on a fear-avoidance measure; at least one hypomobile lumbar segment; and at least one hip with more than 35° internal rotation. This was validated by Childs and colleagues24 in a multicenter randomized, controlled trial of 131 consecutive patients.
Fritz and associates49 reported that those who had positive tests for spinal hypomobility had more successful outcomes if manipulation was included in the interventions; and those with hypermobility were more successful if stabilization was included.
Management: Cervical Spine
Cervical manipulation, in combination with exercise, has been shown to significantly decrease neck pain42,59 as well as increase ROM, upper extremity and neck strength, and endurance.17 Gross and associates59 completed a Cochrane review and identified strong evidence in favor of manipulation combined with exercise to decrease pain when compared with a control group. While the risk of serious or life-threatening injuries has been reported from 1 in 20,000 to 5 in 10 million,60 it is recommended that non-thrust techniques be used due to the potential risk of adverse effects, including a vertebrobasilar artery stroke.35,76
It is important that the thoracic spine is assessed in patients with cervical impairments.77,87 Not only does the thoracic spine move during cervical motion, but it is prone to mobility impairments. In addition, there are common muscle attachments in both regions. Performing joint manipulation and high-velocity thrust of the thoracic spine often improves outcomes in patients with cervical complaints.26,27,77,87
FOCUS ON EVIDENCE
Cleland and Childs26 performed thoracic manipulation, exercise, and patient education for 78 patients with neck pain. An 86% success rate was found for patients with three or more of the following criteria: symptoms <30 days; no symptoms distal to the shoulder, cervical extension does not aggravate the symptoms; Fear-Avoidance Belief Questionnaire-Physical Activity Score of <12; diminished upper thoracic kyphosis (T3–5); and cervical extension <30°.
Management Guidelines: Soft Tissue Injuries
As previously described, symptoms in soft tissues, including muscles, can occur as a result of direct trauma (tears/contusions), strain from sustained or repetitive activities, or as a protective mechanism (guarding/spasm) from injury to joints or other tissues. General guidelines for management follow those presented previously and are summarized in Boxes 15.4, 15.7, and 15.8. In addition, specific considerations when treating muscle injury are described in this section.
Management During the Acute Stage: Protection Phase
Pain and Inflammation Control
Use appropriate modalities and myofascial release techniques to control pain and inflammation. Passive support may be necessary to relieve the muscles from the job of supporting or controlling the injured part.
Cervical collars provide passive support in the cervical region. The length of time a collar is worn during the day relates to the severity of the injury and the amount of protection required.
PRECAUTION: Collars often place the neck in a forward-head posture. This causes healing in a faulty position, which leads to future postural problems or painful syndromes. Usually, turning the collar around or cutting down the portion under the mandible allows the neck to assume correct alignment. Cervical collars are usually reserved for severe and acute whiplash injuries or postoperative intervention per the physician's recommendations.
Corsets provide passive support of the lumbar region. As with the cervical region, the length of time that a corset is worn should be related to the amount of protection required. Some patients tend to become dependent on the corset and continue to wear it even after healing when it no longer serves its intended purpose. After healing, it is better to strengthen the body's natural corset (deep abdominal muscles) and develop effective spinal mechanics (see Chapter 16).
When evaluating muscle function, identify the functional position in which the patient has a decrease in the intensity of symptoms. With a muscle injury, this is often with the muscle in its shortened position. In this position, begin gentle muscle-setting techniques. Dosage is critical; resistance is minimal. Use only enough to generate a setting contraction.
Patient position and procedure: Supine. Stand at the head of the treatment table, supporting the patient's head with your hands. Start with the guarding muscle in its shortened position. Ask the patient to hold as you apply gentle resistance (light enough to barely move a feather). Both the contraction and the relaxation should be gradual. There should be no neck movement or jerky resistance.
If there has been muscle injury, the technique is repeated with the muscle kept in the shortened range for several days before beginning to lengthen it.
As the muscle heals or if there is no muscle injury, progress the treatment by gradually lengthening the guarding muscle after each contraction and relaxation. Movement is performed only within the patient's pain-free range; no stretching is performed when there is muscle guarding.
(Reverse muscle action. These exercises are valuable for gentle muscle performance activity when neck motions cause pain and muscle guarding. The neck is not moved, but the muscles are called on to contract and relax. The motions include active scapular elevation, depression, adduction, and rotation. If symptoms are not exacerbated, active shoulder flexion, extension, abduction, adduction, and rotation are used to stimulate the stabilizing function of the cervical musculature.)
Patient position and procedure: Prone, with arms resting at the side. Have the patient lift the head. This initiates a setting (stabilizing) contraction of the lumbar erector spinae muscles. A stronger contraction of the lumbar extensor muscles occurs if the head and thorax are extended. Alternate hip extension also causes a setting contraction of the lumbar extensor muscles.
When there is muscle injury, the muscle is kept in this shortened range for several days.
For progression as the muscle heals or if there is no muscle injury, gradually allow the muscle to elongate after each contraction by putting a pillow under the abdomen and having the patient extend the thorax on the lumbar spine through a greater range. Elongation is performed only within tolerance during the early healing phase. There should be no increase in symptoms.
Alternate position and procedure: Supine. Have the patient press the head and neck into the bed, causing a setting contraction of the spinal extensors.
Gentle oscillating traction may reflexively inhibit the pain and help maintain synovial fluid and joint-play motion during the acute stage when the muscles do not allow full ROM. Gentle techniques are most effectively applied using manual traction. Position the part with the injured tissue in a shortened position and use a dosage less than that which causes vertebral separation.
PRECAUTION: Traction techniques may aggravate a muscle or soft tissue injury if the tissue is placed in a lengthened position during the setup or with a high dosage of pull during treatment.110
If there are activities or postures that caused the trauma or are continuing to provoke symptoms, identify the mechanism and modify the activity or environment to eliminate the potential of recurrence of the problem.
Management in the Subacute and Chronic Stages of Healing: Controlled Motion and Return to Function Phases
Once acute symptoms are under control, re-examine the patient and determine the impairments and functional limitations. Refer to the general guidelines for management as presented in Boxes 15.7 and 15.8.