Physical Therapy for Thoracolumbar Spine

Functional anatomy, movement

⚫ Functional anatomy of thoracic spine

1. Normally, the thoracic spine, being one of the primary curves, exhibits a mild kyphosis; the cervical
and lumbar sections, being secondary curves, exhibit a mild lordosis.
2. Because the spine and ribs protect vital organs (e.g., heart, lungs, and viscera), it is important that
the examiner be able to differentiate problems with the vital organs from mechanical problems.
3. The costovertebral joints are synovial plane joints located between the ribs and the vertebral bodies,
and radiate ligament stabilize the joint.
 Ribs 1, 10, 11, and 12 articulate with a single vertebra.
 For ribs 10, 11, and 12, it attaches only to the adjacent vertebral body.

4. The costotransverse joints are synovial joints found between the ribs and the transverse processes
of the vertebra of the same level for ribs 1 through 10.
5. The superior facets face up, back, and slightly laterally; the inferior facets face down, forward, and
slightly medially changing from a 45° to 90° inclination.
→ The facet joints limit flexion and anterior translation and facilitate rotation.
6. The spinous processes of these vertebrae face obliquely downward.
7. The ribs help to stiffen the thoracic spine and articulate with the demifacets on vertebrae T2 to T9.
⚫ Functional anatomy of lumbar spine
1. The superior facets, or articular processes, face medially and backward and in general are concave;
the inferior facets face laterally and forward and are convex.
2. These posterior facet joints direct the movement that occurs in the lumbar spine (flexion, extension).
3. The iliolumbar ligament, which connects the transverse process of L5 to the posterior ilium helps to
stabilize L5 with the ilium and to prevent anterior displacement of L5.
4. The intervertebral discs make up approximately 20% to 25% of the total length of the vertebral
column.
5. With age, the percentage of spinal length attributable to the discs decreases as a result of disc
degeneration and loss of hydrophilic action in the disc.

⚫ Muscle of thoracolumbar spine

1. Anterior and posterior chest muscles

2. Abdominal muscles
 3. Erector spine muscles
4. Multifidus
5. Muscles of pelvic area
⚫ Spinal nerve
1. Spinal cord 只到 L1 而已，其餘的部分會形成 cauda equina，因此容易壓到，且症狀很複雜
2. Dermatome, myotome, deep tendon reflex.
⚫ Movement of thoracic and lumbar spine
Common Disorder of Thoracolumbar Spine
⚫ Muscle conditions
1. Muscle guarding and intrinsic muscle spasm
 Symptoms and signs
A. Tension and tenderness of the muscles.
B. Prolonged spasm tends to spread and aggravate symptoms.
 Evaluation
A. Observation, palpation, etc.
B. Find the primary disorder.
 Treatment
A. Reduce the pain and spasm.
B. Treatment primary disorder.
2. Muscle strains and contusions
 Mechanism of injury: trauma history.
 Symptoms and sign:
A. Movement aggravate.
B. Rest relieve but stiffness.
 Evaluation
A. Palpation.
B. Active and passive movement.
C. Resisted isometric contraction.
 Treatment: the same principle of muscle strain.
⚫ Joint conditions
1. Facet joint impingement
 Mechanism of injury
A. Sudden
B. Unguarded movement involving backward bending, side bending, and/or rotation with little
or no trauma.
 Symptoms and signs
A. Certain specific passive and active movements.
B. Resisted and painful.
 Evaluation
A. Position change.
B. Loss of mobility in specific pattern.
 Treatment
A. Mobilization.
B. Traction.
2. Facet joint sprain
 Mechanism of injury: trauma history.
 Symptoms and signs
A. Joint sprain with effusion in and around the joint.
B. More generally movement restricted and involved more than one specific unilateral segment.
 Treatment
A. Rest.
B. Modalities.
C. Pain free movement.
D. Same principle of sprain management.
3. Joint hypomobility
 Symptoms and signs
A. Prolonged immobilization usually secondary to injury or poor posture.
 Evaluation
A. Limit active and passive movement.
B. Observation.
C. Spring test.
 Treatment
A. Mobilization.
B. Stretch exercise.
C. Traction.
D. Modalities.
4. Joint hypermobility
 Joint instability caused by
A. Prolonged posture problem.
B. Congenital defect.
C. Severe trauma.
 Hypermobility can develop adjacent to a hypomobile segment.
  Symptom and signs:
A. General soreness or pain (因為肌肉要一直收縮來維持穩定，因此容易 fatigue).
B. Cannot maintain any position too long.
C. Pain is worse following activity.
 Evaluation
A. Observation.
B. Palpation.
C. Spring test.
 Treatments
A. Muscle strengthening.
B. Support.
C. Surgical stabilization (severe case).
⚫ Degenerative joint / disc disease (DJD/DDD)
1. Mechanism of injury
 Facet osteoarthritis.
 Intervertebral joint spondylosis.
 A chronic and commonly progressive degeneration of facet joints and/or intervertebral disc.
 Frequently an associated osteophytosis of the adjacent vertebrae.

2. Causes
 Natural process of aging and is often symptom free joints continually exposed to trauma.
 Develops as the result of hypomobility or hypermobility.
The size of intervertebral foramen decreasing,
3. Symptoms and signs
 Morning stiffness.
 Pain with movement (especially in extension)
 Hypomobility (more commonly) or hypermobility.
 Pain with or without radiculopathy and neurological sign.
4. Evaluation
 Tender to palpate joints.
 Movement test: extension more pain.
  SLR test
 Neurological sign test: dermatome, myotome, DTR.
 X ray findings.
5. Treatments
 Mobilization
 Manual or mechanical traction.
 Exercise for flexibility, strengthening, stabilization.
 Modalities.
 No loading.
⚫ Disc herniation (herniation intervertebral disc, HIVD)
1. Mechanism of injury
 A displacement of nuclear material beyond the normal confines of the annulus there is a bulge in
the annulus, but no material escapes through the annular fibers.
 Posterior or posterolateral protrusions are most common.
2. Herniation severity
 With protrusion without or with spinal nerve root involvement.
 With extrusion or sequestration.
A. Herniation of the L4–L5 disc compresses the fifth lumbar root.
B. Massive central sequestration of the L4–L5 disc involves all of the nerve roots in the cauda
equina and may result in bowel and bladder paralysis.

3. Symptoms and signs

 Pain on back and/or leg.
 With or without lateral shift.
 With or without sciatica.
 With or without neurological sign.
4. Aggravated factors
 Sitting (especially slump sitting).
 Forward bending (most common).
 With heavy load.
 Decrease lordosis.
 Increase disc pressure.
打噴嚏、咳嗽、便秘也會影響到症狀
 5. Evaluations
 History and symptoms.
 Posture: decrease lordosis.
 Movement test: centralization / peripheralization.
 SLR test (sciatic nerve).
 Neurological sign test.
 CT and MRI findings.

6. Treatments
 Patient education.
 Increase lumbar lordosis.
 Correct lateral shift.
 Extension exercise.
 Traction.
 Corset.
 Modality.
 Operation.
⚫ Osteoporosis and compression fracture
Osteoporosis
➢ 2005-2008 年國民營養調查報告指出 50 歲以上男女骨鬆症盛行率分別為 23.9%及 38.3%
➢ 依 2006 年台灣平均壽命女性為 80.8 歲及男性 74.6 歲推估 而言，大約三分之一的台灣婦
女在一生中會發生一次脊椎體、髖部或腕部之骨折；男性也約有五分之一的風險
➢ 骨質疏鬆症的篩檢
1. 個人生活習慣與家族史、個人疾病史與藥物史 (明顯之風險因子)
2. 現在身高以及年輕時身高 (差 3 公分以上)
3. 體重資料（過輕 BMI<18.5 或 過重）
4. 頭枕部與牆間距(wall-occiput distance, WOD>3 cm)
5. 肋骨下緣與骨盆間距 (rib-pelvis distance, RPD<2 cm)
➢ 危險因子
1. 過去骨折史
2. 吸菸、喝酒
3. 類固醇
4. 類風濕性關節炎
 1. The clinical definition of osteoporosis is based on bone densitometry with dual X-ray
absorptiometry (DXA).
 Between 1.0 and -1.0 standard deviation (SD) is normal bone density.
 Between -1.0 to -2.5 SD is osteopenia.
 Below -2.5 SD is osteoporosis.
2. Male: female = 2 : 8.
 Most common areas: proximal femur, vertebrae, distal forearm, proximal humerus, pelvic.
3. Mechanism of injury: common in senile or postmenopausal.
4. Compression fracture areas: lower thoracic and high lumbar region.

5. Symptom and signs

 Pain.
 Flexion posture.
 Limited spine movement.
6. Evaluation
 Posture evaluation (WDD, RPD).
 X-ray finding.
 DXA and/or FRAX.
7. Treatment
 Prevention.
 Education: food, posture, exercise.
 Avoid flexion exercise, encourage trunk extension.
 Strengthening exercise.
 Weight bearing exercise.
 Spinal brace.
 Stabilization exercise.
⚫ Spondylolysis and spondylolisthesis
1. Spondylosis
 A defect involving the lamina or neural arch of the vertebra (pars interarticularis).
 Usually asymptomatic unless with stressful activities.
 Evaluation: X ray findings.
 Training 以 stretch 為主
2. Spondylolisthesis
  Slipping of the upper vertebra forward on the lower one.
 Mechanism of injury:
A. The most common level is L5 – S1, L4 – L5.
B. 在體操選手與老人常看見
 Symptoms:
A. Pain with or without radiculopathy.
B. With or without neuropathy.
C. Increase lordosis, pelvis anterior tilt.
D. Abdominal muscles and gluteus maximus weakness.
Hip flexor, hamstring and back extensor tightness.
 Evaluation:
A. Observation, palpation.
B. Movement test (extension aggravate symptoms).
C. X-ray findings.
 Treatments: postural improvement
A. Flexion exercise (William exercise).
B. Modalities, brace. (mechanical traction is not using)
C. Surgical management.
D. Stabilization exercise.
⚫ Ankylosing spongylitis
1. Clinical symptoms
 Male: female = 9:1.
 Inflammatory of the spina and SI joint.
 Familial tendency.
 First symptoms in young men.
 Stiff and pain of the spine, especially in the morning.
 Spine fused and movement is severe limitation.
 Pain may in chest, hip and knees may be involved.
 Complication: fracture of spine, medica problems (rare).

2. X-ray findings and laboratory investigation

 First findings: SI joint involvement.
 Syndesmophyte from the vertebral.
 Fusing to form bony bridge (bamboo spine).
 HLA-B27, ESR.
3. Physical examination
  Posture assessment.
 Flexibility of spine.
 Respiratory function.
 Peripheral joint condition.
4. Treatment
 Aims: (1) Retain spinal mobility, (2) Minimize deformity, (3) Relieve pain.
 Exercises: (1) Mobilizing exercise (stretch spine, thoracic cage, hips), (2) Posture correction, (3)
Improve muscle endurance, (4) Avoid vigorous exercise and contact sports.
⚫ Coccyx problem
1. Common subluxation or fracture, becomes sclerosed, and passive movement becomes restricted.
2. History: fall on coccyx, childbirth injury.
3. Symptoms:
Sit problem
Coccyx heal in the more extended position and become hypomobile (normal coccyx flexes while
sitting and extends when standing).
4. Treatment: modalities, environment adaption, mobilization, surgical remove.
⚫ Posture problem
1. Postural correction will be a primary treatment consideration.
2. Patient often younger and may lack general physical fitness.
Lumbar flexion syndrome (Slump back)
 Patient with slump and round lumbar spine (loss lumbar lordosis) while sitting or standing.
 Working-related condition (such as bench worker, slump over the desk).
 Pain is intermittent and only comes on after being in this postural position for a length time.
 Changing posture or position usually brings relief.
 This pain is produced by tension on the PLL and posterior portion of the annulus of the disc.
 Bilateral backache is the chief complaint.
 Avoiding prolonged sitting and standing unless maintaining a lumbar lordosis by using a roll.
 Extension exercise are often necessary to maintain ROM in extension
Lumbar extension syndrome (Sway back)
 Complaint of a dull backache that comes on after standing for several hours, and often covers
large non-specific area.
 Patient with weakness abdominal muscles and joint hypomobility in lumbar spine.
⚫ Pseudospine pain: conditions that mimic spine pain
1. Vascular: abdominal aortic aneurysm.
2. Gynecologic: endometriosis, pelvic inflammatory disease, ectopic pregnancy.
3. Genitourinary: prostatitis, kidney stone.
4. Gastrointestinal: pancreatits, penetrating or perforated duodenal ulcer.
5. Rheumatologic: fibromyalgia, polymyalgia rheumatica.
6. Metabolic: osteomalacia.
7. Malignancy.