Chapter 9 Axial Skelton: Osteology and Artbrology 357 Using Knowledge of Kinesiology to Help Guide Treatment of Chronic Low-Back Pain: Selected Example here are many nonsurgical, therapeutic approaches for treat- ing persons with chronic low-back pain. One reason for the ‘many differing approaches is the frequent lack of understanding of the exact mechanical dysfunction, pathology, and underlying cause of the pain. Pain in the low back can stem from mutiple ‘anatomic sources, including muscle, bone, superficial regions of the intervertebral disc, spinal nerve root or spinal cord impinge- ent, amet, dra mater, esca, orapohysea and sarc Joints, Treatment approaches also vary based on the formal train- ing, clinical experience, and theoretic and philosophical back- ‘ground of the clinician. Some clinicians direct their nonsurgical ‘treatment for low-back pain based primarily on pathoanatomic ot ‘mechanical-based models. Othora, however, rely more on laa: sifying, oF subgrouping, ther patients based on clusters of exami- ration findings that nave been shown to favorably respond to 2 given therapeutic approach. 7% ‘Athorough iscussion of the various physical therapy approaches to chronic low-back pain isnot within the scope ofthis chapter In short, however, approaches include training to improve the strength and control of muscles, selective activation and stretch- ing of muscles and connective tissues to optimize vertebral move- ‘ment and alignment," advice on modifying posture or design of ‘the workplace, mobilization and manipulation,” traction, sott- tissue massage, and physical modalities (e.9., heat, electrical stimulation, and therapeutic ultrasound). Many approaches asso- ciated with'the treatment (as well as diagnosis) of low-back pain involve movement ofthe lumbar region. For this reason the ciii- cian must understand the associated kinesiology. To highlight one example ofthis point, consider the marked and usually contrasting biomechanical effects that are associated with flexion and exten- ‘ion of the lumbar intervertebral junctions (Table 9-10). The eon trasting biomechanics can give important clues as far as the ‘source of pain or mechanical dysfunction, and ultimately the most effective treatment, Nucleus pulposus Annus fibrosus Posterior side stretched Apophysel joint ule etched en ecco nons at Aicular loading deceased Inererebal foramen widened Posterior longitudinal ligament Ligamentum flavum Interspinous ligament Supraspinous ligament Anterior longitudinal ligament Spinal cord Increased tension (elongated) Increased tension (elongated) Increased tension (longated) Increased tension (elongated) Decreased tension (slckened) Increased tension (elongated) Deformed or pushed posteriorly Deformed or pushed anteriorly Anterior side stretched Capsule slackened (neutral extension only) Maximizes articular contact area (neutral extension only) “Aticulr loading inreased Narrowed Decreased tension (sackened) Decreased tension (sackened) Decreased tension (sackened) Decreased tension (slackened) Increased tension (elongated) Decreased tension (sackened) Frontal Plane Kinematics: Lateral Flexion ‘About 20 degrees of lateral flexion occur to each side in the lumbar region.!*}" Except for differences in orientation and structure of the apophyseal joints, the arthrokinematics Of lateral flexion are nearly the same in the lumbar region as in the thoracic region. Ligaments on the side opposite the lateral flexion limit the motion (see Figure 9-55, B). Normally the nucleus pulposus deforms slightly away from the direc tion of the movement, or, stated differently, toward the convex side of the bend.”® Siting Posture and its Effect on Algnment within the Lumbar ‘and Craniocervical Regions For many persons a great deal of time is spent stting~at work, at school, at home, or in a vehicle. The posture of the pelvis dluring sitting can have a substantial influence on the spinal alignment throughout the vertebral column. The topic of sitting posture therefore has important therapeutic implica- tions on the treatment and prevention of problems through- out the axial skeleton. The following discussion highlights the effects of sagittal plane posturing of the pelvis, specifically as it affects the lumbar and craniocervical regions. Consider the classic contrast made between “poor” and “ideal” sitting postures (Figure 9-65) In the poor or slouched posture depicted in Figure 9-65, «4, the pelvis is posteriorly tilted with a relatively flexed (flattened) lumbar spine. Eventu- ally this posture may lead to adaptive shortening in con- nective tissues and muscles, ultimately perpetuating the undesirable posture. A slouched sitting posture increases the extemal moment arm between the line of force of the upper body and lumbar vertebrae (see redline in Figure 9-65, A), This situation places greater demands on tissues that normally resist flexion of the Tower trunk, including the intervertebral discs. As explained358 Section Il Axial Skeleton ody weight FIGURE 9-65. Sicing Bed woight ture and its effects on the alignment of the lumbar and craniocervical regions ‘A, With a slouched sting posture, the lumbar spine flexes, which reduces its normal lordoss. As a consequence, the head tends to assume a forward (protracted) posture (see text) B, With an ideal siting posture, possibly aided ‘with a low-back cushion, the lumbar spine assumes 2 mere normal lordosis, which facilitates a'more desirable “chin-in” (retracted) position of the head. The line of gravity resulting from body weight is shown in red carlier in this chapter, in vivo pressure measurements typi- cally demonstrate larger pressures within the lumbar discs in slouched sitting compared with erect sitting.” Even in healthy persons, the increased pressures from the slouched sitting position can deform the nucleus pulposus posteriorly slightly, especially in the L4-L5 and L5-S1 regions” A habitu- ally slouched sitting posture may, in time, overstretch and thus weaken the posterior annulus fibrosus, reducing its ability to block a posteriorly protruding nucleus pulposus. This biomechanical scenario may be related to the pathogen- «sis of a significant number of cases of nonspecific low-back pain.’ The position of the pelvis and lumbar spine during sitting strongly influences the posture of the axial skeleton a3 far cranially as the craniocervical region." On average, the flat posture of the low back is associated with a more pro- tracted position of the craniocervical region (i.e, a “forward head” posture) (sce Figure 9-65, 4). Sitting with the lumbar spine flexed tips the thoracic and lower cervical regions forward slightly, toward flexion. In order to maintain a horic zontal visual gaze-such as that typically required to view a ‘computer monitor—the upper craniocervical region must com- pensate by extending slightly. Over time, this posture may result in adaptive shortening in the small posterior suboccipi- tal muscles (see Chapter 10) and posterior ligaments and membranes associated with the atlanto-axial and atlanto- ‘occipital joints. As depicted in Figure 9-65, B, the ideal siting. posture that includes the natural lordosis (and increased ante= rior pelvic tilt) extends the lumbar spine. The change in posture at the base (caudal aspect) of the spine has an opti- ‘mizing influence on the adjacent more cranial segments. The ‘more upright and extended thoracic spine facilitates a more retracted (extended) base of the cervical spine, yielding a more desirable “chin-in” position, Because the base of the cervical spine is more extended, the upper craniocervical region tends 10 flex slightly to a more neutral posture. ‘The ideal sitting posture depicted in Figure 9-65, B is dif- ficult for many persons to maintain, especially for several hhours at atime. Fatigue often develops in the lumbar extensor muscles. A prolonged, slouched sitting posture may thus be an unavoidable occupational hazard, at least some of the ‘time. In addition to the possible negative effects of a chroni- cally flexed lumbar region, the slouched sitting posture may also increase the muscular stress at the base of the cervical, spine. The forward-head posture increases the external flexion, torque on the cervical column as a whole, necessitatin ‘greater force production from the extensor muscles and loca Connective tissues. Sitting posture may be improved by a combination of awareness; strengthening and stretching the appropriate muscles; eyeglasses if needed; and ergonomically designed seating, which includes adequate lumbar support. ‘SUMMARY OF THE KINEMATICS WITHIN THE VERTEBRAL COLUMN With the visual aid of Figure 9-66, the following points sum- ‘marize several kinematic themes of the vertebral column. 1. The cervical spine permits relatively large amounts of ‘motion in all three planes. Most notable isthe high degree of axial rotation permitted at the atlanto-axial joint. Ample range of motion is necessary to maximize the movement of the head-the site of hearing, sight, smell, and equilibrium, 2. The thoracic spine peemits a relatively constant amount of lateral flexion. This kinematic feature reflects the general frontal plane orientation of the apophyseal joints com- bined with the stabilizing effect of the ribs. The thoracic spine supports and protects the thorax and its enclosed ins. As described in Chapter 11, an important function, of the thorax is to provide a mechanical bellows for ventilation, 3. The thoracolumbar spin, from a cranial-to-caudal direction, permits increasing amounts of flexion and extension at the expense of axial rotation, This feature reflects, among