통증 물리치료학 및 실습

Gachon University

Department of Physical Therapy Hwi-young Cho, PT, PhD

CH 14. 요통 재활 - 2

3. Stenosis

Spinal Stenosis

• Grouped as “spinal stenosis”

– Central stenosis

• Narrowing of the central part

of the spinal canal

– Foraminal stenosis

• Narrowing of the foramen,

resulting in pressure on the

exiting nerve root

– Far lateral recess stenosis

• Narrowing of the lateral part

of the spinal canal

http://www.whitechiropractic.info/spinalstenosis.html

Spinal Stenosis

http://www.nextavenue.org/article/2012-06/spinal-stenosis-painful-and-frequently-misdiagnosed-condition

Spinal Stenosis

• Symptoms – Leg pain

– Numbness, weakness, and cramping in the legs, feet, or buttocks.

– Stiffness in the legs and thighs.

– Low back pain.

– In severe cases, loss of bladder and bowel control.

http://www.mildprocedure.com/what-is-lss.html

Spinal Stenosis

• 진단 – MRI

– Computerized tomography (CT) scan

– Physical exam

• 비수술적 중재 – Rest during acute phase

– Physical therapy • Exercise/walking

• http://www.youtube.com/watch?v=mcv8lujBI20

– NSAID or Steroid injections

https://www.preferredpaincenter.com/spinal-stenosis.html

Spinal Stenosis

• 수술적 중재 – 비수술적 중재로 실패 시 시행함

– 최후의 선택임

– http://www.youtube.com/watch?v=Bm-MYMM2DBY

– Decompression

http://www.doereport.com/enlargeexhibit.php?ID=72242 Laminectomy & Foraminatectomy

4. Ankylosing spondylitis

• Progressive disease including the chronic pain and muscle spasm

• 20 age, male

• SI joint > Lumbar > Thoracic > Rib

• Bamboo Spine :

– Ossification of the annulus fibrosus, the anterior longitudinal ligament

5. Mechanical Low Back Pain

• http://www.youtube.com/watch?v=sUAHifmzvig

• = Non-specific low back pain

• Nondiscogenic back pain that is provoked by physical activity and relieved by rest.

• Cause

– strain and sprain

– Deconditioning and decompensation

• Overuse = insidious onset

• Pain

– Type: Chronic, dull, aching

– Progressive worsens during the day

• Intervention

– Therapeutic exercise • Yoga or Pilates

• Postural reeducation

• Abdomen and back muscle strengthening

6. Osteoarthritis

• Begin during the third decade of life

• Pain

- Centered in the lower back

- Increased with movement

- Morning stiffness(esp. extended period)

- Relieved by rest.

• Hypertrophic change or spur root compression

• Management

: Postural training

: Abdomen and back muscle strengthening

: when severe, back support for 6 wks (prefer isometric)

7. Scoliosis • A person's spine is curved from side to side (frontal

view).

• C-shape and S-shape

• Occuring : < 14 old

• Female > Male (3~5 times)

http://newbridgespine.com/pain-due-scoliosis/

http://www.fpnotebook.com/_media/BackScoliosisXRay.gif

Scoliosis

• Tx exercise

– http://www.youtube.com/watch?v=188PTlRq1Qo

– http://www.youtube.com/watch?v=wmk5Mvz4pe8

8. Lordosis

• L3 추간판에 가해지는 부하량 :

–누운 자세 < 서있는 자세 < 앉은 자세 <앉아서 앞으로 굽힌 자세

http://stronglifts.com/lordosis-why-it-causes-lower-back-pain-how-to-fix-it/

9. Degenerative disease

Degenerative disc DZ

Degenerative Disease

• The symptoms of pain and possibly radiating weakness or numbness stemming from a degenerated disc in the spine. While the definition sounds simple, many patients diagnosed with degenerative disc disease are left wondering exactly what this diagnosis means for them.

• http://www.youtube.com/watch?v=Q_5U7skcQeM

• http://www.youtube.com/watch?v=SEa4M29xeP4

http://www.doctorpinchback.com/backpain2.html

Disc aging

• Thompson criteria – Loss of cells

– Loss of H20/ proteoglycans

– Type II/ Type I collagen

– Annular fissures

– Mechanical incompetence

– Bony changes

http://chicagosportsmedicine.com/pelvic_pain_2.html

Facet Arthritis

• Changes in disc structure and function can lead to changes in the articular facets, especially hypertrophy (overgrowth), resulting from the redirection of compressive loads from the anterior and middle columns to the posterior elements

http://3dprecisiondiagnostics.com/articular-facet-anatomy-traumatic-arthritis-r1559701x.aspx

Disc height 과 Facet joint 는 상관관계가 있음을 나타냄.

Degenerative Disc Disease

• 진단 – MRI/CT

– Discography

– Physical examination

• 비수술적 중재 – 휴식: 급성의 경우

– Steroid & NSAID medication

– Physical therapy • Exercise/walking

• Low-impact aerobics

• Trunk strengthening

Degenerative Disc Disease

• Surgical care – Failure of nonoperative treatment

• Minimum of 6 weeks

– Fusion • Removal of disc and replacement with bone graft, or

a cage-filled bone graft, or a bone graft substitute – Anterior approach – Posterior approach – Combined approach

– http://www.youtube.com/watch?v=H8sK7ABcin4 – Arthroplasty

• Articulating disc replacement

Lumbar Fusion

• Fusion procedure used to treat:

– Spondylolisthesis

– Spondylolysis

– DDD

• Multiple approaches

– Posterior, anterior, transforaminal, combined anterior/posterior

Posterior Lumbar Fusion

• Posterolateral fusion (PLF) – 적용대상: Spondylolisthesis

and spondylolysis without disc involvement

– Involves adding bone graft to an area of the spine to set up a biological response that causes the bone to grow between the two vertebral elements and thereby stop the motion at that segment.

http://www.methodistorthopedics.com/posterior-lumbar-fusion

http://www.methodistorthopedics.com/posterior-lumbar-fusion

Lumbar Arthroplasty

• Total disc replacement (TDR)

– DDD

– Contraindicated for spondylolisthesis and spondylolysis

The CHARITÉ Artificial Disc is indicated for spinal arthroplasty in skeletally mature patients with DDD at one level from L4-S1.

http://www.jkma.org/search.php?where=aview&id=10.5124/jkma.2007.50.6.523&code=0119JKMA&vmode=PUBREADER#!po=10.0000

Tx procedure

Brief summary for diagnosis &

treatment

Outline

• List essential components of a LBP history,

including Red flags

• Review proper indications for imaging

analysis

• Review Physical Examination for LBP

– Identify Red flags

• Discuss acute or chronic management options

General Questions -Important-

Onset

Location

Mechanism of Injury

Radiation

Positional change

Numbness, tingling

Weakness

Red Flags

• Age > 50

• IV drug use

• Hx/o cancer

• Prolonged steroid use

• Osteoporosis

• Distal numbness

• Saddle anestesia

• Bowel or bladder loss

• Fever

• Trauma

• Unexplained wt loss

• Pain at rest/night

• Weakness

Diagnoses & Red Flags • Cancer

– Age > 50

– History of Cancer

– Weight loss

– Unrelenting night pain

– Failure to improve

• Infection – IVDU

– Steroid use

– Fever

– Unrelenting night pain

– Failure to improve

• Fracture – Age >50

– Trauma

– Steroid use

– Osteoporosis

• Cauda Equina Syndrome – Saddle anesthesia

– Bowel/bladder dysfunction

– Loss of sphincter control

– Major motor weakness

Diagnoses & Red Flags • Cancer

– Age > 50

– History of Cancer

– Weight loss

– Unrelenting night pain

– Failure to improve

• Infection – IVDU

– Steroid use

– Fever

– Unrelenting night pain

– Failure to improve

• Fracture – Age >50

– Trauma

– Steroid use

– Osteoporosis

• Cauda Equina Syndrome – Saddle anesthesia

– Bowel/bladder dysfunction

– Loss of sphincter control

– Major motor weakness

Outline

• List essential components of a LBP history,

including Red flags

• Review proper indications for imaging

analysis

• Review Physical Examination for LBP

– Identify Red flags

• Discuss acute or chronic management options

Tests

Imaging

XR

CT

MRI

Imaging

X Ray CT Scan MRI

Imaging Guidelines

Choice to do imaging based on:

Historical red flags

Trauma, chronic steroid use = XRay

Suspect abscess, cauda equina = MRI

Exam red flags

Midline TTP = Xray

New/severe sensory or strength loss = consider MRI

Outline

• List essential components of a LBP history,

including Red flags

• Review proper indications for imaging

analysis

• Review Physical Examination for LBP

– Identify Red flags

• Discuss acute or chronic management options

Physical Exam Rule-out most concerning things

• Concerning features

– Midline TTP

– Decreased strength

– Diminished reflexes

– Sensory loss

• Reassuring features

– Paraspinal muscle spasm

– Full strength

– No sensory deficits

Six-Point MSK Exam

• Inspection

• Palpation

• ROM

• Strength

• Neurovascular

• Special Tests

Inspection

Ensure

No obvious deformities

No erythema

Skin lesions (Zoster)

Palpation

Soft Tissue

4 clinical zones

Paraspinal muscles

Gluteal muscles

Sciatic area

Anterior abdomen/abdo

minal wall

• Bones

– Primarily palpating

spinous processes and

facets

Flexion - 80º

Extension - 35º

Side bending - 40º each side

Twisting - 3-18º

Range of Motion

Neurologic

Testing

• Sensation

• Strength

• Reflexes

http://mddirect.org/tag/dermatomes/

Neurologic Examination

(L4 level)

Motor

Tibialis Anterior

Resisted inversion of ankle

Reflexes

Patellar Reflex (L2, L3, L4)

Sensory

Medial side of leg

http://quizlet.com/15681576/phmd-6010-wk-1-4-written-no-tests-flash-cards/

Neurologic Examination

(L5 level)

Motor

Extensor Hallicus Longus

Resisted dorsiflexion of great toe

Reflexes - none

Sensory

Dorsum of foot in midline

http://quizlet.com/15681576/phmd-6010-wk-1-4-written-no-tests-flash-cards/

Neurologic Examination

(S1 level)

Motor

Peroneus Longus and Brevis

Resisted eversion of foot

Reflexes

Achilles

Sensory

Lateral side of foot

http://quizlet.com/15681576/phmd-6010-wk-1-4-written-no-tests-flash-cards/

Special Tests

Tests to stretch spinal cord or sciati

c nerve

Tests to stress the sacroiliac joint

Straight leg raise

Looking for lumbar disk herniation

Performed supine for best sensitivity

Positive when radiating pain observed at 30-70 degress of hip flexion

Very high sensitivity, but low specificity

Should also do the crossed-leg straight leg raise

Positive when they have pain when you lift and adduct the opposite leg

FABER Test

• = Patrick test

• Flexion Abduction External Rotation Test

• To assess for – both Sacroiliac Joint (SIJ) pain

– anterior/lateral hip capsular tightness

• Pain in the anterior thigh is indicative of Hip pain.

• Pain posteriorly is indicative of SIJ pain.

• http://www.youtube.com/watch?v=XCOD1dkcVk0

• http://www.youtube.com/watch?v=V1a0E0ssTqA

FABER test: Flexion A- Bduction External Rotation

FADIR Test

• Flexion Adduction Internal Rotation Test

• To assess for

– Hip impingement (Femoroacetabular impingement)

• Anterolateral Hip pain suggestive of hip

Impingement (Femoroacetabular impingement)

• http://www.youtube.com/watch?v=36hGS6xf_8Y

FADIR test:

Flexion

A-

Dduction

Internal

Rotation

Hoover Test

Helps to determine whether pt is malingering

Should be performed in conjunction with SLR

When pt is genuinely attempting to raise leg, h

e exerts pressure on opposite calcaneus to gain

leverage

http://www.youtube.com/watch?v=_cchOvhY

yxA

Inducing factors of LBP

AGE Trauma OA

Osteoporosis

smoking

obesity

dancer

W lifting

DM EXERCSIE

Rotation operation

LBP

Prolo

therapy

OP

Root

BLOCK

REST

EXTENSION

EX

PT DRUG

Therapeutic methods

Therapeutic goal

Operation

IDET(추간판내 열응고술)

PDN (Prosthetic disc nucleus)

연성디스크 삽입술

(고합성물 물질 – 폴리머)

TDR(인공디스크 전치환술)

PT materials for TX of LBP

• PT modalities

– Hot / cold pack

– Electrical modalities

• Manual therapy

–칼텐본, 메잇랜드, 추나, 카이로프락틱

• Exercise

History of Spine Rehabilitation

“Early on bed rest was the treatment of

choice for most back pain”

50’s and 60’s

* Flexion

* Posterior pelvic tilt

70’s – Extension (Robin McKenzie) – “Back school” – Modalities (Heat, US, ES, Traction, Massage) – Joint mobilization

80’s

- Stabilization Training

(Northern California)

Superficial layer Deep layer

http://www.netterimages.com/image/9986.htm https://bedahunmuh.wordpress.com/2010/05/11/muscles-of-back-deep-layers/

Abdomial muscles Erector spinae

http://www.hoopdaloop.com/hoopblog/ http://lyndseydesjardins.com/functional-anatomy-part-7-intrinsic-back-muscles/

Local and Global muscles

* Attaching directly to the lumbar vertebrae. * Controls curvature of spine * Responsible for segmental stability. * Maintain or decrease intervertebral motion

Local muscles (intersegmental muscles)

* The large torque producing muscle linking the pelvis to the thoracic cage. * Balance outer load (gravity, lifting object,etc) * Providing general trunk stabilization

Local and Global muscles

Global muscles

(multisegmental muscles)

Lumbar Stabilization

Stabilization implies the ability of an individual to control, consciously or unconsciously, macroscopic and microscopic movement at a joint.

- Magee(1999) -

Stabilization training is to eliminate repetitive injury to the intervertebral discs, facet joints and related structures.

Lumbar Stabilization

The three systems active spinal stabilization

PASSIVE SUBSYSTEM

- Spinal column

ACTIVE SUBSYSTEM

- Spinal Muscle

CONTROL SUBSYSTEM

- Neural

SPINAL STABILITY

Stability model Panjabi (1992)

Lumbar segmental stability

The local muscle system has a primary responsibility for segmental stability.

It appears that both multifidus(다열근) and transverse abdominis(복횡근) are important components of this system.

Multifidus

Multifidus demonstrated greater fatiguability relative to other parts of the erector spinae in Chronic back patients compared to a normal population.

Biederman et al (1991)

transverse abdominis

Hodges and Richardson (1995), EMG experiment, analyzing the onset of activity of the muscles of the abdominal wall in response to “arm movement” , the timing of onset of

transverses abdominis was delayed in chronic low back pain.

Shoulder movement Normal

Flexion Abduction Extension

the relaxed the drawn-in

The action of the transverse abdominis

Spine Functional Layers

Outer Layer Larger movement-Big power

muscles

Middle Layer Slightly thicker muscle across 2~5 vertebrae-

includes abdominal muscles

Deep Layer Tiny muscles, span-from one vertebra to the next.

Current Trends

• Yoga

• Pilates

• Lumbar stabilization exercise

• Core exercise

• The CORE program

Peggy W. Brill, PT.

Purpose of exercise therapy

• Muscle strengthening in weak ms.

• Muscle Imbalance correction

• Stretching the shorten soft tissue

• Increase flexibility on the lumbar region

structures

• Correction of lumbar curvature

Exercise therapy

William ex. Emblass ex. Golthwaite ex. 신장 운동

· 체간 굴곡 운동 · 요추 전만 감소가 목적 · 전복부근, 대둔근, 슬 괵 근 능 동 적 근력강화 · 천극근, 고관절굴근, 대퇴직근 수동신장

· 요추 신전 운동 · HIVD·요통에 실시 · 운 동 강 도 의 점차적인 증가 · 휴식시간 및 운동 횟수 적절히 조정

· 만성 요통에 실시 · 척 추 배 부 근 의 근력강화

· 근육의 단축으로 자세이상을 가져왔을 때 실시 · 지속적 신장 권장

견인 시 고려사항

㉠ 견인력 : 누워있는 사람을 수평이동하기 위해 체중의 1/2에 해당하는 견인력 필요

㉡ 견인각 : Pelvic harness와 strap의 위치에 의해 결정

㉢ 견인자세 : 엎드려 누운 자세에서 실시

견인 치료시 적응증

적응증 금기증

· 추간판 탈출증 · 척추의 퇴행성 관절염 · 편타성 손상(채찍손상 · whiplash injury) · 오십견(frozen shoulder) · 사경(torticolis) · 변형성 척추증 · 추궁절제술 후 통증시 · 골연골증

· 척추 골절 · 종양 · 급성 염좌·좌상 · 심한 골다공증 · 식도열공 헤르니아(hiatus hernia) · 밀실공포증(Claustrophobia) · 척추분리증 · 임신 3~4개월경의 임산부

Recommend TX program

1. Precise diagnosis

2. Proper Intervention for reducing pain Ice or thermal TX

TENS (Pain) and U/S (Soft tissue)

Traction or other aiding material

3. Manipulation for fixing alignment of bony structures

4. Exercise Intervention for correct body alignment and recovery muscle function

Practice

• HNP (=SLR, compression)

• Facet syndrome (=extension)

• SI joint (=FABER test)

• Valsalva maneuver

• Pelvic alignment (leg length, PSIS)

• Palpation of spinous process (scoliosis)

• Correct vertebra

FABER test • Purpose: To assess for the sacroiliac joint or hip joint being the

source of the patient's pain.

• Test Position: Supine.

• Performing the Test: The patient's tested leg is placed in a "figure-

4" position, where the knee is flexed and the ankle is placed on

the opposite knee. The hip is placed in flexion, abduction, and

external rotation (which is where the name FABER comes from).

The examiner applies a posteriorly directed force against the

medial knee of the bent leg towards the table top. A positive test

occurs when groin pain or buttock pain is produced. Due to forces

going through the hip joint as well, the patient may experience

pain if pathology is located in the hip as well.

• http://www.youtube.com/watch?v=iYMqhWf7XVk

Sarcoiliac (SI) joint TX

• Mobilization

– http://www.youtube.com/watch?v=ptmt72Fxoq4&list

=PLee-9L8i_xLXbEnDXdWCnJnM4oMlG_aIb

– http://www.youtube.com/watch?v=tGDjpVvEo5Q

• Manipulation

– http://www.youtube.com/watch?v=NhwECwj3LDI