THE SPINE:

MANAGEMENT
GUIDELINES

Dr. Shafaq Shahid

Lecturer
DPT,MS-OMPT
 Spinal Pathologies and
Impaired Spinal Function
Pathology of the Intervertebral Disc
Continue…
• Fatigue breakdown. Over time, the annulus breaks down as a result
of repeated overloading of the spine in flexion with asymmetrical
forward bending and torsional stresses.
• Traumatic rupture. Rupture of the annulus can occur as a one-time
event. This is seen most commonly in traumatic hyperflexion injuries.
• Axial Overload: (compression) of the spine usually results in end-
plate damage or vertebral body fracture before there is any damage
to the annulus fibrosus.
• Scheuermann’s disease occurs when the nucleus migrates either
superior or inferior through a cracked end-plate.
Continue…
• Age: Individuals are most susceptible to symptomatic disc injuries
between the ages of 30 and 45 years.
• Degenerative Changes: Any loss of integrity of the disc from infection,
disease, herniation, or an end-plate defect becomes a stimulus for
degenerative changes in the disc.
• Effect on Spinal Mechanics: Injury or degeneration of the disc affects
spinal mechanics in general. During the early stages, there is
increased mobility of the segment with greater than normal
flexion/extension and forward and backward translation of the
vertebral body, leading to segmental instability.
Pathomechanical Relationships of the IV Disc
and Facet Joints
• As the disc degenerates, there is a decrease in both water content
and disc height.
• The vertebral bodies approximate, and the intervertebral foramina
and spinal canal narrow.
• This is called degenerative disc disease (DDD).
• Eventually, with the repeated irritation due to the faulty mechanics,
there are progressive boney changes in the facet and vertebral body
margins. This is known as spondylosis, osteoarthritis (OA), or
degenerative joint disease (DJD).
Continue…
• Segmental instability has been described as poor control in the
neutral zones within the physiological range of spinal movement
because of a decrease in the capacity of the neuromuscular stabilizing
system to control the movement.
• Stenosis is narrowing of a passage or opening. In the spine, stenosis is
any compromise of the space in the spinal canal (central stenosis),
nerve root canal, or foramen (lateral stenosis); it can be congenital or
acquired and can occur at any age.
Continue…
• Spinal nerve root or spinal cord symptoms occur:
• When protrusion of the disc compresses against the cord or nerve roots.
• When there is an inflammatory response due to trauma, degeneration, or
disease with accompanying edema and stenosis.
• When spondylosis results in osteophytic growth on the articular facets or
along the disc borders of the vertebral bodies.
• When there is spondylolisthesis or when there is scarring or adhesion
formation after injury or spinal surgery.
Pathology of the Zygapophyseal (Facet) Joints
• Facet Sprain/Joint Capsule Injury: There is usually a history of
trauma. The joints react with effusion (swelling), limited range of
motion (ROM), and accompanying muscle guarding. The swelling may
cause foraminal stenosis and neurological signs.
• Spondylosis, Osteoarthritis, and DJD: Osteoarthritis involves
degeneration of the IV disc as well as the facet joints. Usually, there is
a history of faulty posture, prolonged immobilization after injury, or
severe or repetitive trauma.
Continue…
• Ankylosing Spondylitis (AS): AS is a rheumatic disease characterized
by chronic inflammation of the ligaments in the lumbar and spinal
areas. The inflamed cartilage/boney junction will fuse in
approximately 20% of the population.
Pathology of the Vertebrae
• Compression Fracture Secondary to Osteoporosis:
• Vertebral compression fractures most often occur in the thoracolumbar
region as the result of a fall or trauma or from performing basic ADLs that
require forward bending of the trunk.
• Fractures usually occur during the sixth or seventh decade of life in the
anterior vertebral body.
• Pain may be referred to the low back or abdominal region with or without
lower extremity radiculopathy.
• Patients present with increased thoracic kyphosis (sometimes called
dowager’s hump) and lumbar lordosis secondary to instability, boney
changes (wedging), and muscle weakness.
Continue…
• Scheuermann’s Disease: It is a rare congenital and/or degenerative
weakening of the vertebral endplates, typically seen at T10–L2.
• The nucleus pulposus can protrude vertically into the vertebral end-
plate, which can lead to a boney necrosis or Schmorl’s nodes.
• Scheuermann’s disease may also be caused by insufficient blood
supply to the growing bone.
• This pathology is usually seen in the second decade of life and may be
diagnosed as “growing pains.”
Pathology of Muscle and Soft Tissue Injuries:
Strains, Tears, and Contusions
Pathomechanics of Spinal Instability
• The neutral zone is the area that is mid-range in the ROM of a spinal
segment in which no stress is placed on the passive osteoligamentous
structures.
• In the spine, the neutral zone is relatively small (usually only several
degrees of range is possible between any two vertebrae before the
elastic zone of the inert tissues is reached) and is controlled by
dynamic tension in the deep segmental musculature that attaches to
each of the spinal segments.
Continue…
• If there is an increase in the neutral zone, the segment may show
signs of instability.
• The individual may experience neck or back pain when aberrant
movement occurs at the segment or stresses are imposed at the end
of the range (relaxed postures for a period of time or sudden stress
that the muscles cannot control).
Management Guidelines Based
on Stages of Recovery and
Diagnostic Categories
 Principles of Management for the Spine

• Examination and evaluation:

• Disabilities are dependent on the extent of the injury.
• If it involves the spinal cord, levels of complete paralysis may occur.
• If it involves the nerve roots, varying degrees of sensory loss in specific dermatomes and muscle
weakness in specific myotomes may occur, which may or may not interfere with the individual’s
daily personal and work-related activities.
 Continue…

• A history and systems review of the patient is conducted to rule out any serious conditions,
determine if the patient should be referred to another practitioner, or determine if the patient’s
condition is appropriate for physical therapy intervention.
• Serious “red flag” conditions related to orthopedic conditions that should be referred to a
physician for management include spinal cord symptoms and signs, recent trauma and serious
pain that cannot be explained mechanically.
 Continue…

• Psychological distress may interfere with a patient’s recovery.

• Neurological symptoms should be explored in an attempt to relate them to spinal cord, nerve
root, spinal nerve, plexus, or peripheral nerve patterns.
• Pain patterns should be explored to determine if they relate to a known musculoskeletal pattern
or signal a medical condition.
Management Guidelines: Nonweight-Bearing
Bias
• During examination, some patients do not respond to extension, flexion, or even mid-range spinal
positions or motions due to the acuity of or mechanical stimuli from their condition.
• The person is often more comfortable lying down and may have partial or full relief with a
traction test maneuver to the painful region of the spine.
• For these patients, use of traction procedures or unweighting the body in a pool may be the
interventions of choice until the symptoms stabilize.
 Continue…

• Traction has the mechanical benefit of temporarily separating the vertebrae, causing
mechanical sliding of the facet joints in the spine, and increasing the size of the intervertebral
foramina. If done intermittently, this motion may help reduce circulatory congestion and relieve
pressure on the dura, blood vessels, and nerve roots in the intervertebral foramina.
 Continue…

• Harness: Various unloading devices or body weight support systems may be used, such as
partially suspending the patient in a harness while he or she performs ambulation on a treadmill
or gentle extremity exercises.
• Pool: If a person is not fearful of being in a pool, supporting the individual with a buoyant life
belt in deep water reduces the effects of gravity on the lumbar spine.
Management Guidelines: Extension Bias
• Patients with an extension bias often assume a flexed posture or a flexed posture with lateral
deviation of the trunk or neck, but during the examination, sustained or repetitive extension
maneuvers reduce or relieve their symptoms.
• The impairments may be due to a contained intervertebral disc lesion, fluid stasis, a flexion injury,
or muscle imbalances from a faulty flexed posture.
• McKenzie developed a method of categorizing these patients based on the extent of their pain
and/or neurological symptoms.
• He also described the phenomena of peripheralization and centralization.
 Continue…

• Effects of Postural Changes on Intervertebral Disc Pressure

• Effects of Bed Rest on the Intervertebral Disc
• Effects of Traction on the Intervertebral Disc
• Effects of Flexion and Extension on the Intervertebral Disc and Fluid Stasis
• Effects of Isometric and Dynamic Exercise
• Effects of Muscle Guarding
Management Guidelines: Flexion Bias
• Patients may present with a flexed posture and be unable to extend
because of increased neurological symptoms and decreased mobility;
these patients would benefit from early interventions that emphasize
flexion of the involved segments to relieve symptoms.
• The patients may have a medical diagnosis of spondylosis or spinal
stenosis (central or lateral), an extension load injury, or capsular
impingement or swollen facet joints, so symptoms increase with
extension.
• The flexed position reduces or relieves the symptoms.
Continue…
• Indications. Flexion is used if neurological and/or pain symptoms are
eased with flexion and worsened with extension positions or motions.
• Management of Acute Symptoms
• Rest and Support
• Functional Position for Comfort
• Cervical Traction
• Correction of Lateral Shift
• Correction of Meniscoid Impingements
Management Guidelines: Stabilization

• Patients with segmental instability—including hypermobility; ligamentous

laxity; diagnoses such as spondylolysis, spondylolisthesis, or poor
neuromuscular control of the deep segmental and global stabilizing
musculature—require interventions that improve stability.
• Some of the patients may have a history of trauma, repeated
manipulations, or early signs of spondylosis.
• Mobility testing of the spinal segments reveals increased mobility at one or
more segments.
• There may be decreased activity in the stabilizing musculature, particularly
in response to postural perturbations, and there may be faulty respiratory
patterns.
Continue…
• Principles of Management:
• Passive Support
• Deep Segmental Muscle Activation
• Progression of Stabilization Exercises
Management Guidelines:
Mobilization/Manipulation
• When describing or documenting manipulation techniques used, the
clinician is reminded to define the intensity (grade I–IV or HVT) as well
as spinal level (target), direction of force application, and patient
position. Some patients benefit from spinal manipulation during the
early stages of intervention.
• Hypomobile spinal segments may add to stress of hypermobile
segments and require a combined approach of manipulation as well
as stabilization exercises.
Management Guidelines: Soft Tissue Injuries
• Management During the Acute Stage:
• Pain and Inflammation Control
• Muscle Function
• Traction
• Management in the Subacute and Chronic Stages of Healing:
Controlled Motion and Return to Function Phases