DPT 732: Spine, hip, core & pelvic floor

When the CoG falls outside of the BoS, one of these outcomes occur (2)

Structure will fall OR

Forces keep the structure upright

Spinal stability occurs with these subsystems (3)

Passive: Bones and ligaments

Active: Muscles

Neural control

What is the function of the global muscles that act on the spine? Describe their size

Superficial muscles that cross multiple vertebral segments and produce motion and stability against perturbations

Examples of global muscles of the spine (8 total)

Rectus abdominis

External/internal obliques

QL

Erector spinae

Iliopsoas

SCM

Scalenes

Levator scapulae

What is the function of the core muscles that act on the spine? Describe their size

Deep muscles that attach to each vertebral segment and control segmental motion

Examples of core muscles of the spine (6 total)

TA

Multifidus

QL

Deep rotators

Rectus capitis anterior and lateralis

Longus colli

This motion is a necessary prerequisite for limb motion

Spinal stabilization

Inhalation increases intraabdominal pressure, which affects stabilization in this way

Increases stabilization

Exhalation decreases intraabdominal pressure, which affects stabilization in this way

Decreases stabilization

Bracing via breathing exercises activates this muscle (your natural weight lifting belt)

TA

List the stages of recovery for LBP, including the time frame (note that it's different from other tissues) (5 stages)

Acute with inflammation: 0-4 weeks

Acute w/o inflammation: 0-4 weeks, intermittent symptoms

Subacute: 4-12 weeks

Chronic: Over 12 weeks

Chronic pain syndrome: Over 6 months

Can chronic LBP patients handle high intensity exercises?

Yes, if performed correctly

What does it mean if a patient with LBP has a NWB bias? How do we approach tx?

Patient doesn't tolerate being upright for ADLs. Movement makes pain worse

Tx: Traction

What does it mean if a patient with LBP has an extension bias? How do we approach tx? Give an example of a condition that might fall into this category

Patient presents with flexed posture and/or lateral shift

Tx: Extension exercises decrease or centralize pain

Ex. IVD problems

What does it mean if a patient with LBP has a flexion bias? How do we approach tx? Give an example of a condition that might fall in this category

Patient presents with flexed posture being more comfortable

Tx: Avoid extension, which exacerbates or peripheralizes pain

Ex. Spondylosis, stenosis, facet

Treatments for patients with LBP presenting with hypermobility/ functional instability (2)

Strengthen active stabilizers

Core muscle strengthening at level of hypermobility

Treatments for patients with LBP presenting with hypomobility (2)

Mobilization and manipulations

Stretching and ROM work

Treatments for patients with LBP presenting with muscle and/or soft tissue lesions (2)

Exercise approach (rehab the muscle)

Guarded posture and muscle tension release

Treatment for patients with LBP presenting with postural pain syndrome (3)

Patient education

Movement posture correction

Increase strength in proper posture

Define a trunk muscle strengthening and endurance exercise. What sort of condition would this be useful for?

Exercise training prescribed to restore of improve strength, endurance or power of trunk muscles or muscle groups

Ex. Use isometrics with hypermobility

Define a specific trunk muscle activation exercise. What sort of condition would this be useful for?

Exercise training that targets specific deep trunk muscles (ex. TA) using co-contraction to alter or restore control or coordination of lumbopelvic region

Ex. Use VPAC progression for pelvic floor

Define a movement control exercise. What sort of condition could this be useful for?

Exercise training that alters, restores, or retrains control of functional movements and tasks with feedback on movement patterns.

Ex. Using biofeedback bag on cervical muscle training

When would general exercise be helpful for conditions affecting the spine, hip, core or pelvic floor?

When you want to generally improve strength or endurance of the major muscle groups

Define a trunk mobility exercise. When could this exercise be useful?

Exercise that restores trunk ROM, can help reduce symptoms.

Ex. Happy Baby pose helps flex back and hips, opens pelvic floor muscles

When would aerobic exercise be useful for conditions of the spine, hip, core or pelvic floor?

When you need to restore or enhance the capacity of the CV system

Ex. If a patient with scoliosis is having trouble breathing

In the acute phases of a spinal condition, start with these things in your plan of care (6)

Patient education

Pain management

Awareness of neck and pelvic position and movement

Safe postures

NM activation and stabilization of muscles

Safe performance of ADLs

In the subacute phases of a spinal condition, include these things in your plan of care (6)

Pt education

Awareness and control of spinal alignment

Increase ROM

NM control, strength, endurance, aerobic fitness

Stress relief

Body mechanics

In the chronic phases of a spinal condition, include these things in your plan of care (6). What must we integrate into?

Spinal control

Increase ROM, performance, dynamic trunk strength, coordination, endurance

CV endurance

Stress relief

High intensity activities

Self-maintenance

Integrate into ADLs

Fundamental categories of training for spinal rehab (names + description) (3)

Kinesthetic training: Manual and verbal cueing

Stabilization training: Deep muscles

Functional training: ADLs

How to progress spinal stabilization training (7 steps)

1. Safe spinal motions and neutral spinal position

2. Activate deep muscles in neutral

3. Add extremity motions

4. Increase reps

5. Use alternating isometrics

6. Change positions

7. Use unstable surfaces

Examples of lumbar stabilization exercises (3)

Abdominal bracing

Posterior pelvic tilt

Multifidus activation and training

How to progress lumbar stabilization exercises (in general) (3 steps)

Stabilize

Load limbs

Functional tasks

What is VPAC? How is it useful?

Volitional preemptive abdominal contraction

Used to teach patients to progressively brace core and strengthen core and pelvic floor

The Williams Flexion protocol is an example of an exercise protocol that can be used to improve this motion

Improves lumbar flexion and avoids extension

Manages LBP non-surgically

Do hip muscles affect posture?

Yes, direct attachments to the pelvis means that hip muscles directly affect spinal posture

The focus of improving muscle performance at the hip is to...

Develop control of hip movement while keeping good trunk stability

Muscle imbalance at the hip that can cause hip and LBP may be d/t abduction dominated by this muscle instead of glute med

TFL

Pelvic floor problems may occur in patients with these other conditions (5)

Hip pathology

Spine pathology

Chronic pain

Anxiety

Depression

These conditions may directly cause pelvic floor problems (3)

Post-partum

Post-prostatectomy

Trauma (orthopedic or IPV)

Does everyone need pelvic floor activation exercises (ex. kegels?)

No, for some patients there is already too much tone so they need to calm down

Pelvic floor strengthening should initiate in this position (1) and then progress through these positions (5)

Supine with hips elevated

Supine

Side-lying

Quadruped

Sitting

Standing

These contractions should be avoided during pelvic floor contractions, so that we can isolate PF muscles (4)

Glute contractions

Ab contractions

Hip adductors

Valsalva