Spine/Pelvis Flashcards
Core strength vs stability
Core strength is the ability of the muscles to exert or withstand force. Core stability describes the ability of the body to control the whole range of a joint so there is no major deformity, neurological deficit, or incapacitating pain.
Name the local and global muscles of the core
Local: Multifidi, TA, internal oblique, medial fibers of external oblique, diaphragm, QL, pelvic floor muscles (multifidi/TA are primary stabilizers since the don’t create movement in spine)
Global: Rectus abdominis, paraspinals, psoas, lateral portion of external oblique
Characteristics of local stabilizers vs global muscles (outside of the obvious ones)?
- Aponeurotic vs fusiform connections to bone
- 30-40% MVC vs >40%
- Slow vs Fast Twitch
- Short vs long lever arms
Functional role of TA and multifidi
TA = attaches to the linea alba and TL fascia and will tense these up to increase intra-abdominal pressure and stiffen the spine and resist forces acting on it.
Multifidi= span 1-3 vertebral levels and don’t have adequate moment arm for rotation but rather, local segmental stability.
These muscles do not really cause movement of the spine, in fact, the TA is more active with abdominal hollowing and less EMG activity with lumbopelvic movement. They precontract prior to limb movement to stabilize the spine.
Stabilizers and people with low back pain?
People with low back pain and lumbar instability are found to have weak local stabilizers (TrA and multifidi).
Core strength and stability findings?
Individuals who are shown to have strong global core muscles don’t necessarily have equally conditioned endurance of local muscles.
Abdominal hollowing and bracing?
Hollowing is proposed to activate TrA with minimal activation of global muscles (isometric abdominal wall contraction without spine movement). Bracing is coactivation of all abdominal muscles. Currently, it is suggested to hollow for static exercises and brace for more dynamic exercise with external loads.
Panjabi’s Systems and How To Train Them
3 systems:
1. Passive
2. Active
3. Neural
Training of active system focuses on improving function of local system prior to global system and start with exercise with little/no movement, low resistance, and endurance. Global system trained after. Neural system focuses on enhanced timing, coordination, and reflexes.
Research on optimal progression for core training?
Little research. Recommended to progress based on FITT principle.
Quadriparesis vs quadriplegia
Unlike quadriplegia — which is a full paralysis or inability to move all four limbs — quadriparesis is characterized by overall weakness in your arms and legs, but you can still feel and move your limbs.
Transient quadriplegia/quadriparesis
Quadriparesis: mechanism is usually cervical hyperextension. Symptoms usually 10-15 minutes, however, some patients may have residual symptoms up to 36 hours. May be burning pain and motor/sensory disturbances in all 4 limbs.
Quadriplegia: associated with cervical stenosis, kyphosis, presence of congenital fusion, cervical instability, and/or disc protrusion/herniation
Torg Ratio
AP diameter of spinal cancel divided by AP vertebral body diameter. Evaluates for congenital stenosis of c-spine. Extremely sensitive (90%) but low specificity for determining further injury.
If lower ratio then more likely to have burner (one study showed if ratio less than 0.8 there was 3x > risk of stinger compared to those over this.
Stinger/Burner
Temporary episode of unilateral UE burning with motor weakness. Common in collision sports. Symptoms radiate from neck to fingertips and deltoid/biceps (C5,C6) most commonly involved. Symptoms usually last a few seconds to minutes but could persist for as long as a few weeks.
Injury mechanisms could include:
1. Stretch/traction to brachial plexus
2. Cervical extension (resulting in nerve root compression)
3. Direct blow to brachial plexus from shoulder pads
When can athletes return to play after burner/stinger?
Relative contraindication = Torg ratio <0.8 and asymptomatic but h/o burner (they can go back to play but they are at risk for re-injury)
Absolute contraindication = Neuropraxia with MRI findings of cord abnormality (edema, ligamentous instability, neuro symptoms >36 hours, and/or multiple episodes of neuropraxia)
Spinal conditions/symptoms that are not contraindications to contact/collision sports
- Klippel-Feil Syndrome (congenital fusion of 1 or more cervical levels) with full ROM and no instability
- Spina bifida occulta
- Healed, stable, non-displaced fractures with full ROM
- Asymptomatic disc herniations
- H/O cervical fusion (except AA) who are pain-free and neurologically intact
- Asymptomatic Torg <0.8
- DDD with occasional stiffness and no strength changes
- 2 or less stingers in same season
- Single/multiple level laminectomy/foraminotamy
Spinal conditions that are relative contraindications
- Previously healed upper cervical spine fracture (non-displaced Jefferson fracture, healed type 1/type 2 odontoid fracture, healed lateral mass fracture of C2)
- Healed, minimally displaced vertebral body compression fracture
- Healed stable practice of posterior elements (excluding spinous process fracture)
- After healed 2-3 level cervical fusion
- Previous h/o transient quadriparesis/quadriplegia and full ROM/strength and pain-free
- 3+ stingers in same season
Absolute contraindications to return to contact/collision sports
- Odontoid anomalies
- OA fusion
- AA instability
- AA rotary fixation
- Certain Klippel-Feil anomalies associated with mass fusion of cx and tx spine, limited ROM, other occipitocervical anomalies, or instability (type 1 = mass fusion, type 2 = one or two)
- Spinal instability (3.5 mm or more horizontal displacement of one vertebra on another or > 11 degrees of rotation difference compared with adjacent vertebra)
- Acute fracture of body or posterior elements
- Healed body fractures with malalignment
- Canal compromise from fracture that led to bony fragments in this area
- Continued pain, neuro findings, or limited motion from healed fracture
- Disc herniations with neuro findings
- One-level fusion after diffuse congenital narrowing of cervical canal
- MRI evidence of Arnold-Chiari malformation
- More than 2 episodes of transient quadriparesis/quadriplegia
- Continued discomfort, neuro deficit, or decreased ROM after spinal injury
- RA
When to return after transient quadriplegia
May return after 1st episode once symptoms completely resolve, there is full ROM, normal cervical spinal curvature on MRI, CT, or myelogram.
Multiple episodes of transient quadriplegia
Serious consideration given to disallowing return to contact and collision sports.
Can an athlete go back in to the game after transient quadriparesis?
They should sit out the rest of the match, even if symptoms resolve.
How to handle sustained symptoms on sideline with quadriparesis
They have a fracture until proven otherwise. Cervical orthosis applied if can’t rule out fracture and has sustained sx’s.
Can athlete return to play after stinger?
If they have complete resolution of symptoms, return to baseline ROM, and full strength. If it’s just brief then they are okay. If the symptoms are sustained or more severe they should get MRI before returning to play.
If athlete has sustained stinger symptoms, what images should be done?
Radiographs: AP, lateral (C1-T1), and odontoid views and MRI. If occult c-spine fracture is suspect, CT should be performed
Manipulation Criteria
- No symptoms distal to knee
- Acute onset (<16 days)
- FABQ work subscale <19
- Hypomobility of lumbar spine
- One hip >35 degrees internal rotation
Studies strongly support that if you just pay attention to 2 factors they will have positive response (acute onset and no symptoms distal to knee)
If they have 4/5 items they’re very likely to respond, 2/5 or less not likely to respond
Stabilization Criteria
- Younger age (<40 years)
- Greater general flexibility (postpartum or SLR ROM >91)
- Instability catch or aberrant ROM during lumbar ext/flex ROM
- Positive findings for prone instability test
Positive is 3/4
Specific Exercise Criteria
Extension:
- Symptoms distal to buttock
- Centralize with extension
- Peripheralize with flexion
- Directional preference for extension
Flexion:
- Older age (>50)
- Directional preference from flexion
- Imaging evidence of lumbar spinal stenosis
Lateral Shift:
- Visible shift
- Directional preference for lateral translation movements of pelvis
Traction Criteria
- Signs and symptoms of nerve root compression
- No movements centralize symptoms
What radiographic views should be done for young athlete with LBP?
- Standing AP
- Standing lateral
- If lumbosacral region is involved then add oblique views
Common causes of back pain for those under 10 versus those over 10
Under 10:
Discitis, vertebral osteomyelitis, leukemia, eosinophilia granuloma, neuroblastoma, astrocytoma
Over 10:
Most common are spondylolysis, spondylolisthesis, Scheuermann’s Kyphosis, HNP, apophyseal ring fractures. Osteosarcoma and osteoblastoma more common in this age group.
