Lab 4: Back and Pelvis

1. Lab 4: Back and Pelvis Group 5 Jessi Bradley Tara Roberto Corrin Porter Kathryn Pearson Matt Verboom Jimmy Warner

2. Functional Ability Tests -Flexion -Extension -lateral rotation -Lateral Flexion

3. Case Study • A 45 year old male suffered from a muscular tear to the erector spinae at level L2 of the spinal column and experienced muscular spasm and extreme pain due to the lifting motion performed while lifting a case of beer from the trunk of his car. The patient is 50 lbs overweight. He is sedentary and has problems adhering to an eating control plan. He has been treated for muscle spasm with anti inflammatory medication and muscle relaxants. He has also received physiotherapy treatment to enable mobility and basic movements only. He now has 60% flexion range and is 20 degrees from full flexion and is limited in lateral flexion and rotation. Work related activities include driving a delivery van and unloading packages up to 100 lbs plus he enjoys golf as a recreational activity 3 times a week. The client has been referred for physiotherapy and has been treated for 2 weeks and now requires range testing, flexibility and strengthening exercises.

4. The General Scan • Look for any one of the following conditions: • Deformations • Symmetry/Asymmetry • Swelling • Skin discolouration/echymosis • Palpate for scar tissue • Check for structural deformities • Pain Scale 1-10 • Mechanism of injury (ie. Lifting the case of beer)

5. Contraindications and Precautions for Range of Motion Testing • Active and passive range of motion are not to be assessed if any of the following conditions are present in a client: • If a dislocation or unhealed fracture is present • Immediately following surgery only if motion to the area will not interfere with the healing process • The presence of myositis ossificans. The client should be referred to a professional who maintains expertise in this area.

6. Contraindications and Precautions (continued) The therapist must take great caution when performing AROM and PROM assesments where motion can irritate a condition further. • Presence of infections or inflammation • Patient taking pain medication or muscle relaxants • Region marked by osteoporosis or where bone fragility is a factor • Hypermobility or subluxation at the joint • Regions with hematoma • Patients with hemophilia • Regions with boney ankylosis is suspected • Regions with newly united fractures • Prolonged immobilization of a joint.

7. Functional test #1 Trunk Flexion • Ask client to tie shoe lace, or pick up an object off the floor.(90-95 % of full flexion) • Bend over until client feels mild discomfort or pain • Ask patient to move from standing to sitting and return to standing position. (Requires 56-66% of full lumbar ROM) • Once trunk is in “critical position” erector spinae muscles relax and further flexion occurs through hip flexion. (greater than 70% and often between 80-90%) • Trunk flexion initiated by contraction of abdominals and vertebral portion of the psoas major m. • Prime movers of trunk flexion are the abdominal muscles (rectus abdominus, internal/external obliques) • iliopsoas and psoas major are secondary movers

8. Functional test #2 Extension • Ask client to bend over and pick up box • Watch as client extends upward • Erector spinae(longissimus, iliocostalis,spinalis mm.), multifidus as well as gluteal muscles allow for extension of the upper torso • Erector spinae muscles contracts to initiate trunk extension in standing position. • When extension is performed against resistance, the erector spinae muscle contracts to perform the entire movement. • Ie: when in prone position the trunk is extended to reach for a light switch located at the head of the bed. • When lifting objects off the floor from a forward flexed position, there is no contraction of the erector spinae muscles at the beginning of the lift. The thoracolumbar fascia, posterior intervertebral ligaments, and the elastic forces created by the extensor take the load to extend. Then the erector spinae takes over at the “critical position.” • The range of motion during extension is limited by the spinous processes of the vertebrae.

9. Functional Test #3 Trunk Lateral flexion • Not often used in activities. Ask client to pick up an object from a low table while facing perpendicular to that object. • Ask patient to move from side-lying position to sitting position • Lateral flexors contract on the ipsolateral side to initiate movement and contract on the contralateral side to modify movement to upright position. • Erector spinae, intertransversarii, and posterolateral fibers of the external abdominal oblique, qudratus lumborum, and iliopsoas muscles contribute to lateral flexion of the trunk. • The range of motion is limited by the inferior aspect of the ribs contacting the iliac crest.

10. PASSIVE RANGE OF MOTION • Passive movement when used as an assessment method is called passive range of motion or PROM, and muscle length assessment • The therapist uses PROM to determine the ROM at a joint, end feel, and the length of muscles • Normal range of motion for lumbar spine flexion is 0-80 degrees

11. PROM: Flexion Test for Flexion in the Thoracolumbar Spine • Start Position: The patient is standing with feet shoulder width apart • End Position: The patient flexes the trunk forward to the limit of motion for thoracolumbar flexion • Measurement: A tape measurer is used to measure the distance between the spinous processes of C7 and S2. A measure is taken in the start position and at the limit of motion. The difference between the two measures is the thoracolumbar spinal flexion range of motion (about 10 cm) • Substitution/Trick Movement: None

12. PROM: Flexion Test for Flexion in the Lumbar Spine • Start Position: The patient is standing with feet shoulder width apart • End Position: The patient flexes the trunk forward to the limit of motion • Measurement: A tape measurer is used to measure a distance and make a point 10cm about the spinous process of S2. A measure is taken in the start position and at the limit of motion. The difference between the two measures is the lumbar spinal flexion range of motion. The method of measurement is referred to as the modified Schober Test • Substitution/Trick Movements: None

13. Ligaments for Flexion of the Trunk Anterior Longitudinal Ligament • a thick band of fibrous tissue that runs along the anterior surfaces of vertebral bodies. It extends from the anterior tubercle of the atlas bone inferiorly down the full length of the spinal column to fuse with the upper, pelvic surface of the sacrum. It guards against hyperextension of the spine Supraspinal Ligament • The supraspinal ligament (supraspinous ligament) is a strong fibrous cord, which connects together the apices of the spinous processes from the seventh cervical vertebra to the sacrum; at the points of attachment to the tips of the spinous processes fibro cartilage is developed in the ligament. It is thicker and broader in the lumbar than in the thoracic region

14. Interspinal Ligament • The interspinal ligaments (interspinous ligaments), thin and membranous, connect adjoining spinous processes and extend from the root to the apex of each process. They meet the ligamenta flava in front and the supraspinal ligament behind. They are narrow and elongated in the thoracic region; broader, thicker, and quadrilateral in form in the lumbar region; and only slightly developed in the neck Ligamentum Flavum • The ligamenta flava connect the laminæ of adjacent vertebræ, from the axis to the first segment of the sacrum. They are best seen from the interior of the vertebral canal; when looked at from the outer surface they appear short, being overlapped by the laminæ. Each ligament consists of two lateral portions which commence one on either side of the roots of the articular processes, and extend backward to the point where the laminæ meet to form the spinous process; the posterior margins of the two portions are in contact and to a certain extent united, slight intervals being left for the passage of small vessels

15. Posterior Longitudinal Ligament • The posterior longitudinal ligament is situated within the vertebral canal, and extends along the posterior surfaces of the bodies of the vertebræ, from the body of the axis, where it is continuous with the membrana tectoria, to the sacrum. • It is broader above than below, and thicker in the thoracic than in the cervical and lumbar regions.

16. Muscles for Flexion of the Trunk Rectus Abdominus • Muscle Origin: crest and superior ramus of pubis; ligaments covering the anterior surface of the symphysis pubis • Muscle Insertion: 5th, 6th, 7th costal cartilages

17. External Abdominal Oblique • Muscle Origin: 8 digitations from the external and inferior surfaces of the lower 8 ribs • Muscle Insertion: anterior half of the outer lip of iliac crest; as the inguinal ligament into the anterior superior iliac spine and pubic tubercle

18. Internal Abdominal Oblique • Muscle Origin: lateral 2/3rds of the inguinal ligament; anterior 2/3rds of the iliac crest; the thoracolumbar fascia • Muscle Insertion: inferior borders of the ¾ lower ribs; pubic crest and medial aspect of the pecten pubis

19. PROM: Extension Trunk Extension in the Erector Spinae • Start Position: patient lying in prone position with feet over end of bed and pillow under abdomen • Stabilization: strap can be placed over pelvis to isolate lumbar extensors or can use hand on lower back. Therapist places other hand proximal to ankles to stabilize legs. • Movement: Grade 1-2: hands by side and raise off bed as high as is comfortable Grade 3-4: hands behind back and lift Grade 5: hands behind head and lift • Substitution/trick Movement: None • Resistance: Not applied manually because the it is provided through arm positioning . The resistance is increased as the upper extremities are moved towards the head.

20. Muscles for Extension of the Trunk Primary Muscles: • Erector Spinae • Iliocostalis thoracis/ lumborum • Longissimus thoracis • Spinalis thoracis • Semispilalis thoracis • Multifidus Accessory Muscles: • Interspinales • Quadratus lumborum • Latissimus dorsi

21. PROM: Lateral Flexion • Start Position: The patient is standing with the feet shoulder width apart • Stabilization: None • End Position: The patient laterally flexes the trunk to the limit of motion • Measurement: A tape measure is used to measure the distance between the tip of the third digit and the floor • Substitution/Trick Movement: Trunk flexion, trunk extension, ipsilateral hip and knee flexion, and raising the contralateral or ipsilateral foot from the floor

22. Muscles of Lateral Flexion Lateral Flexion • Erector spinae • Intertransversarii • Posterolateral fibers of the: -External abdominal oblique -Quadratus lumborum -Iliopsoas

23. PROM: Lateral Rotation • Start Position: The patient is sitting with the feet supported on a stool and the arms crossed in front of the chest • Stabilization: The therapist stabilizes the pelvis • End Position: The patient rotates the trunk to the limit of motion. The therapist visually estimates the trunk rotation ROM (45 degrees). • Substitution/Trick Movement: Trunk flexion, trunk extension, and shoulder horizontal abduction in the direction of trunk rotation.

24. Muscles of Lateral Rotation Lateral Rotation • Erector spinae • Multifidus • Trunk rotatores • Internal and external abdominal oblique’s

25. Soft Tissue Involved in Lateral Flexion & Rotation • Saggital plane; Frontal Axis • - anterior longitudinal ligament • - anterior atlantoaxial ligament • - anterior fibres of annulus • - anterior neck muscles • Frontal plane; Saggital axis • - spinal ligaments • - fibres of the annulus • Horozontal plane; Vertical axis • - costovertebral ligaments • - annulus fibrosus of the Intervertebral discs

26. Active Range of Motion • Active range of motion or AROM is when the therapist moves the patient into the desired range of motion until the point of discomfort or pain. • The same movements as done for passive range of motion are then performed actively with the therapists assistance. • The therapist much careful not to move the patient into the end of range too quickly because may reproduce pain and therefore must inform the patient when the movement has gone far enough, if the therapist is not before met with great resistance.

27. Active Range of Motion Movements • Flexion: Standing to the side of the patient place one hand on their thoracic spine and other on their lower and slowly bring them into forward flexion. Have them relax their hands down towards their toes and go as far as they will allow. • Extension: Have the patient lying in the prone position and get them to move their arms appropriately through each test grade (1-5) until they can no longer life their chest from the table. • Lateral Flexion: Patient stands with feet shoulder width apart. Therapist presses on opposite side of the hand they wish to reach down towards the knees (ie: apply pressure on right should, therefore bending towards left knee). • Lateral Rotation: Can be done sitting or standing. Patient crosses arms over chest and therapist moves them in to lateral rotation. Therapist applies pressure on right shoulder to have them turn right and holds left hip so they are just moving from lumbar spine, not the hips.

28. Exercise Prescription Factors • It is extremely important to take caution with the spine when prescribing exercise. The therapist must take into consideration the patient’s ROM and make note of any substitutions or trick movements that might be present. For example with trunk flexion the hip flexors can come into play if the rectus abdominis m. is weak. Our patient’s trunk flexion at the moment is limited to 60% which causes the rectus abdominus muscles to activate flexion to this point while the hip flexors come into play during the last 30-40% of the hip flexion. Therefore following the recovery phase focus will have to be put on strengthening and developing stabilization in the hip flexor muscles. Furthermore, because of the presence of slight scarred tissue of the erector spinae around L2 the client will need to strengthen the lower back muscles once soft tissue recovery has completed.