Interventions for the Spine
PTA 104 Ortho Dysfunctions

Basic Concepts of Spinal Management with Movement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution for commercial purposes. It is not intended to serve as medical advice or treatment. Contact howardc@lanecc.edu for permissions.

Introduction

Note: There are approximately 20 minutes of screencasts with the instructor as part of this interactive lecture.

Time to complete suggested active-learning activities and self-checks within the lecture is estimated at 1-1.5 hours

Video approximately 13 minutes

Connecting spine exercise selection and progression to prior learning

In your Applied Kinesiology 2 course (PTA 133L), you practiced methods for measuring ROM and strength in the spine. Core stabilization concepts were introduced during Week 1 in PTA 133 as you learned about the structure and function of the thoracic and lumbar spine. Your study of Kinesiology has reinforced the meaning of basic, intermediate, and advanced stretching and strengthening techniques as it relates to normal muscle function. By now, you have spent some time working on your observation and assessment skills in determining factors which may influence postural tendencies.

In PTA 104 and PTA 104L, we expand on the skilled exercise interventions by carefully selecting and applying therapeutic exercise in order to facilitate optimal tissue healing and return to function. Exercise prescription in orthopedic conditions is specific to a pathological condition resulting in an impairment based movement syndrome. Exercises applied inappropriately or indiscriminately can result in further damage to vulnerable or healing structures. PTAs are trained to recognize when exercise progression is appropriate, when to modify and exercise or movement-based approach and when to refer back to the PT should symptoms indicate a regression or change in condition.

Objectives

1. Identify muscles on stretch during a flexibility exercise
2. Describe instructions and techniques to activate core spinal muscles
3. Select the most appropriate position to rest the lumbar spine for a given case scenario
4. Calculate ideal mechanical traction force for decreasing spinal symptoms in a given case scenario
5. Explain ways to progress difficulty of stabilization exercises
6. Select the most appropriate exercise for a given spinal disorder
7. Describe points of emphasis for patient education in acute, subacute, and chronic stages of recovery from spinal injury
8. Select the optimal frequency of aerobic exercise for end-stage spinal rehabilitation and injury prevention
9. Compare and contrast the effects of various aerobic exercises on the spine
10. Recommend a work site modification for spinal injury prevention for a given case example

Review of Structure and Function

Functional Components of the Spine

• anterior pillar: vertebral bodies and intervertebral discs; weight bearing and shock absorbing
• posterior pillar: vertebral arch = articular processes and facet joints; provides motion and bony levers as points of attachment for dynamic and stabilizing muscles

Stages of Recovery

This table adds subcategories to the "acute" and "chronic" stages of recovery. Patients present in the clinic with acute findings, such as high pain levels and restricted motion, without a known source of inflammation or trauma. It also includes some general functional limitations that patients present with during these stages.

By understanding typical functional limitations along this continuum, a PTA can help educate patients on what is expected in a typical course of treatment and rehabilitation. When patients understand why they need to progress or limit activity and the expected goal of these behaviors, they are more likely to adhere to a home exercise and activity program.

Additionally, the "chronic" stage can refer to a patient who is seeing a physical therapist for the first time, and has complained of spine and related pain and limited function over a longer period of time. These patients may be referred to as experiencing "persistent" pain. Patients who experience persistent pain may present as "acute without signs and symptoms of inflammation". When the physical therapist and treatment team have determined that the spine pain and related functional loss is relatively unresponsive to conservative and other interventions, the physical therapy plan of care typically focuses on management strategies. Management strategies include, but are not limited to: breathing, pacing and prioritizing, a range of exercises (from gentle motions to resistance training), mindfulness and meditation, topical analegesics, heat, and sleep education).

Common Spinal Impairment Classifications

Treatment-based classification strategies can help prioritize interventions based on the PT examination findings. Symptoms of spinal pathology can overlap, therefore, the physical therapist will develop a plan of care based on special tests and measures which lead to a movement-based syndrome classification.

In your clinical practice, you will encounter references to several classification systems (e.g., McKenzie, Sahrmann approach, Delitto, Williams flexion). If you can focus your exercise application on a solid rationale of kinesiology, keen observation, patient input, and understanding of pathology, then you can successfully collaborate with your PT partner on treatment planning and modification to reach maximum function.

Centralization and Peripheralization

Centralization refers to movements that minimize radicular findings, namely, that isolate symptoms in the spine and remove or reduce symptoms that are lateral to the spine or extend into the extremities. Activities that centralize symptoms generally lead to decreased mechanical strain to the affected spinal unit. Peripheralization is a lateral spreading of symptoms from the spine toward or into the extremity. Activities or positions that result in radiating symptoms away from the spine are avoided.

Click here to see an image of centralization vs. peripheralization

Delitto Impairment-Based Categories

 McKenzie Classification System

Clinical Decision-Making and Problem-Solving

Before selecting the most appropriate intervention for your patient, it is important to have a firm understanding of involved structures and tissues, healing stages, and risk for recurrence or further injury.

PTAs provide an extensive amount of education to patient's during all stages of healing. By integrating kinesiology and pathological knowledge, the patients you work with will be more likely to understand the why of the exercise. Patients want to get better, and PTAs can help patients build the necessary confidence to believe in the evidence: progressing posture, movements, and performing the selected exercises consistently and as prescribed, is time well spent.

When thinking about your role, plan for data collection, options for modifications, and indications to communicate with the PT. By planning ahead, you can have multiple interventions to choose from based on the patient presentation and response. Most importantly, you can be listening, feeling, and watching for signs and symptoms which indicate the patient is unable to safely participate in physical therapy.

First, do YOU have any questions about the patient's condition and readiness for treatment? Do you have any questions or concerns about your own confidence and skill set to move forward with treatment? Are you uncertain about elements in the plan of care (including precautions and contraindications) or the PTs directions? If you have questions in these areas, consult the supervising PT for clarification and direction.

Decision-Making Strategies

1. Start with subjective data collection

Clinical pearl: let them know you believe movement is valuable and important by asking about it first

Ask the patient about their movement, daily activity, how long they are able to stand/sit/walk, or other relevant functional targets in the physical therapy plan of care.

Then, ask your patient about other signs and symptoms that relate to the complaint, this may include pain, sensory changes, and aggravating positions or movements.

Ask your patient if there are any other general health concerns

2. Make comparisons

Apply your understanding of healing/recovery stages to the subjective data by collecting relevant objective data:

Observe patient movements, positions and postures. Identify position of bias, if any.

Test and measure specific motions, joints, muscles, endurance, or other indicators relevant to the case as needed based on subjective data and observations or as directed by the supervising PT.

Decide if what you hear and what you see matches findings in the physical therapy plan of care and knowledge of healing stages.

Modify and/or progress interventions based on your data and evidence-informed decisions.

Remember, you have the PTA Problem Solving Algorithm process to help guide clinical-decision making. 

Active Learning Exercise

Video approximately 15 minutes

Fill in the table with interventions you have learned so far that would be consistent with managing acute spinal symptoms. Then use a 0-5 scale to rate your understanding and confidence in selecting the intervention and delivering clear and evidence-based instruction

After completing the table above, proceed on through the lecture and refresh interventions from Kinesiology. Consider what you already know when intentionally selecting exercises based on impairment classifications. 

Active Learning Exercise

1. Position yourself in sidelying. Note the amount of side bending in the lumbar spine and weight bearing pressure in the contralateral shoulder and greater trochanter.

2. Repeat with hand towel rolled into a cylinder and placed under waistline

3. Now try this (Look familiar? It comes from PTA 101 Positioning lecture and your Priniciples & Techniques of Patient Care text)

What are the differences in your comfort level? If you needed to be in a sidelying position on a treatment table for greater than 5 minutes, which of the three options would you choose?

Congratulations! This is an example of how you can apply prior knowledge of interventions for soft tissue protection into a therapeutic activity that allows the patient to assume a position of ease in sidelying.

Basic Concepts of Spinal Management with Movement

Note: All images in this section are attributed to: Olson S, VHI Exercise Images , Tacoma, Washington:Visual Health Information, 1999

All patients should be engaged in motor learning and training regardless of their functional level. Specific training elements include:

• Kinesthetic Training: patient education on safe spinal motions with integration and application to activities of daily living
• Functional Training: applying principles of body mechanics during everyday activities, including prevention
• Stabilization Training: accessing and contracting muscles which provide spinal stability during gross motion

Elements of Kinesthetic Training

Position of bias = position of symptom relief; also known as the "resting position". This image shows how to teach a patient to use the position of ease for comfort.

Neutral spine = spine segments maintain neutral motion in all planes while in a position or performing a movement.

Emphasis is on bringing the patient's attention to what reduces symptoms and what aggravates symptoms and then educating and instructing them on methods to find and use positions of relief or methods to assume and maintain a neutral spine as a therapeutic activity.

The goal: increase awareness of muscle imbalances, or habits that lead to spine imbalance, and understanding of how these length-tension relationships affect symptoms.

Kinesthetic Training Examples

Recall from PTA 101L when you practiced moving into anterior and posterior pelvic tilt, then found your "neutral". You used kinesthetic awareness and instructions and feedback from faculty to inform your understanding of how to find that "neutral spine". Here are some other examples of kinesthetic training for function:

• facilitating movements between "slouched" and neutral posture in sitting and standing
• using fixed objects, like doors and walls as a kinesthetic reference
• using your hand or the patients hand to provide feedback when unwanted movement occurs during a stabilization activity'
• noting signs of tight structures during movement by perceiving compensations
• allowing the patient to feel what takes place at the lumbar spine during prone knee flexion (tight hip flexors);
• allowing the patient to feel how head position will shift forward when reaching overhead (tight chest and restricted scapula);
• allowing the patient to see a Trendelenberg sign with single limb stance activities.

Examples of Kinesthetic Training in Cervical Spine

• Facilitated passive ROM with verbal cues with transition to active-assisted and active range of motion.
• common affected muscles include SCM, scalenes, upper trapezius, pectorals, levator scapula, suboccipitals
• Patient is positioned according to symptom tolerance (WB vs. non-WB)
• Supine positioning when first learning these techniques is recommended.
• Walls and doorways can be used for transition to PWB

Examples of Kinesthetic Training in Lumbar spine

Priniciples of kinesthetic training are used when teaching a patient how to use passive positioning for symptom reduction and progression to submaximal exercises and mid-range motions. For example:

• Hook-lying is non-weight bearing. It is ideal for initiating kinesthetic training in pelvic tilt motions due to slight flexion in lumbar spine. Hooklying promotes posterior pelvic tilt and lumbar flexion. Hooklying is often a position of ease and can be used to to teach submaximal abdominal and low back exercise.
• Prone is non-weight bearing. Patients may lie flat or use a pillow under the pelvis to accomodate as needed. Prone can be used to train a neutral spine while activating low back, hip (extensor, rotators) and scapula muscles.
• Sitting positions can be used to place a patient in a position of ease for the lumbar spine. For example, sitting with feet propped on footstool promotes lumbar flexion; with feet flat and lumbar roll promotes extension; use of arm rests in sitting promotes decreased WB in lumbar spine
• Standing positions such as placing one foot on a stool/block promotes posterior pelvic tilt. More advanced techniques can include the use of dynamic surfaces, like foam rollers

Kinesthetic Training with Limb Motion

The goal: perceive no significant compensatory movement at the spine when performing progresive limb loading activities. Demonstrate neuromuscular control by activating primarily stabilizers (spine) and producing appropriate direction and force of primary movers.

Teach client how controlled and correctly sequenced limb motion influences control of spine symptoms during functional activities: rolling, sit to stand, bending, etc.,

Again - recall from your PTA 101L experience: how did you teach a patient to move from supine to sidelying to sit? You applied principles of limb loading to reduce forces needed to sit up, and part of this included awareness of sequenced movements and minimizing forces on the spine.

In this image, the patient is trying to control the position of the head and cervical spine while the chest opens and shoulders abduct. Any compensatory motion of the head and neck, like flexing away from the door or being unable to maintain arms against the wall, would be felt by the patient and practiced again to prevent compensation. These observations may also guide decision-making for stretching interventions.

Postural and Functional Training Elements

When there are imbalances in postural, passive and active exercises restore length-tension relationships. These exercises and movements are used to mobilize joints and soft tissues. The key element is that these are performed correctly and at low frequency intervals throughout the day. Traction forces are stretching forces which may be used to decompress inflamed nerve root structures, thus decreasing pain.

The goal: Minimize or eliminate restrictions that prevent assuming and maintaining a neutral spine during sustained positions and activities

Self-mobilization examples for areas of hypomobility:

• extending over a foam roller or towel
• extending over a chair
• sidebending over a therapy ball
• rotating over a fixed pelvis
• rotating over a fixed upper trunk

• quadruped rock (rocking back into heels) can help a patient identify posterior soft tissue restrictions or poor abdominal control

Functional training should be patient-specific as determined by the physical therapy plan of care. Patients should begin to practice basic functional training without the use of a load, then progressively work towards performing activities typical for their home and work environment.

In this example, a patient with a history of cervical pain would practice placing and removing moderately light objects on low surfaces while minimizing stress and strain to the neck using sliding shelves:

Elements of Stabilization Training

The Dutton text provides excellent examples of these progressions for the cervical and lumbar spine

• Basic
• posterior pelvic tilt; cervical retraction
• drawing-in maneuver
• isometric multifidus contraction
• Intermediate - Spinal stabilization with limb loading - Notice the activities keep the body in double limb support, then progress to single limb support to increase control of flexion, extension, and rotation; although included as lumbar stabilization, consider the role of WB in UEs and limb movement on cervical and thoracic stability
• Hooklying heel slide
• Hooklying knee lift
• Hooklying bent knee fall out
• Sidelying clam shell
• Prone limb lifts
• single limb (arm/leg)
• double limb (arm leg)
• Quadruped limb lift
• single limb (arm/leg)
• opposite arm/leg lift
• Advanced - Focus is on increasing dynamic control with progressive increased resistance and decreased BOS to increase strength and endurance for return to function
• Side planks
• Side planks with limb loading (lifting arm or leg away from midline)
• Bridging (with double and single limb support, static and dynamic surfaces ( Bosu/Therapy ball, foam roll)
• Abdominal strengthening with limb loading

Shirley Sahrmann has adapted a sequence of exercises for spinal stabilization using limb-loading principles.

Video approximately 5 minutes

We suggest that you practice on your own or instruct a willing participant in each of the exercises. Many patients will need continuous feedback in the initial stages of learning and your own experience with practice can help you appreciate concepts of feedback and motor control

Self Checks

Summary of Spine Rehabilitation Progressions

Approximately 6 minutes

Active Learning Exercise

Fill in the table with interventions you have learned so far that would be consistent with managing subacute / controlled motion spinal symptoms. Then use a 0-5 scale to rate your understanding and confidence in selecting the intervention and delivering clear and evidence-based instruction

Now compare your tables for acute and subacute conditions of the spine. How do they differ? Can you see indications for a progression? Would you be able to identify when it is appropriate to progress a patient? Can you provide patient-centered education in the above areas? Use the CAN YOU HELP ME? forum to discuss your findings.

End of Lesson

I encourage you to complete the tables and share ideas in the course forums. Consider creating a brief video and posting some exercises you might select for a patient with a subacute or acute condition.