Post Micro Lumbar Disectomy


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Doctoral presentation on segmental stabilization. Roger Meade, PT

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Post Micro Lumbar Disectomy

  1. 1. Roger James Meade, PT
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  3. 3. <ul><li>Two vertebrae separated by an intervertebral disc </li></ul><ul><li>Nerves that leave the spinal column at each vertebra </li></ul><ul><li>Small facet joints that link each level of the spinal column </li></ul>
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  6. 6. <ul><li>Main purpose is to provide segmental stability </li></ul><ul><li>Cephalic attachment is to the spinous processes & lamina of a vertebra </li></ul><ul><li>Lie on each side of the spinous processes </li></ul><ul><li>Five fascicles (bands) in each multifidus muscle </li></ul><ul><li>Shortest fascicles are the deepest, travel 2 vertebrae caudally attach to mamillary process of vertebra just beyond the margin of facet joint </li></ul><ul><li>When weak play a role in spinal disc dysfunction </li></ul>
  7. 7. <ul><li>Fear of Re-injury </li></ul>
  8. 8. <ul><li>Fear of Re-injury </li></ul><ul><li>Prevent Regaining Normal Spine Function </li></ul>
  9. 9. <ul><li>Fear of Re-injury </li></ul><ul><li>Prevent Regaining Normal Spine Function </li></ul><ul><li>Make You More Susceptible To Injury </li></ul>
  10. 10. <ul><li>Work to regain segmental posture control </li></ul><ul><li>Activate Multifidi muscle </li></ul><ul><li>Overcome the fear of re-injury by a controlled logical progression of challenges to the spine </li></ul>
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  12. 12. <ul><li>Reduce harmful and excessive stress </li></ul>
  13. 13. <ul><li>Reduce harmful and excessive stress </li></ul><ul><li>Promote Healing </li></ul>
  14. 14. <ul><li>Reduce harmful and excessive stress </li></ul><ul><li>Promote Healing </li></ul><ul><li>Promote Dynamic Stabilization (Normal Function) </li></ul>
  15. 15. <ul><li>Specific back exercises for the back and abdominal wall that focus on deep stabilizing muscles have proven to reverse motor control deficits that occur after back injury, surgery, or degenerative changes </li></ul>
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  19. 19. <ul><li>Achieving the ‘ideal response’ is practically impossible for patients with a history of back injury. </li></ul><ul><li>Research shows that the brain develops a dysfunctional movement-coordination programming strategy after a back injury or degenerative changes. </li></ul><ul><li>Inner unit muscles are impaired and no longer have tonic-holding capacity. </li></ul><ul><li>Outer unit muscles are excessively active during low-loading on spine. </li></ul>
  20. 20. <ul><li>Multifidi do not return to normal function automatically </li></ul><ul><li>Postural awareness does not return to lumbar spinal segments involved </li></ul><ul><li>Patients need confidence to overcome fear of injury </li></ul><ul><li>Patients need to understand possible limitations from surgery </li></ul>
  21. 21. <ul><li>Reprogram the brain to use a separate strategy control of the inner unit muscles. </li></ul><ul><li>Retrain muscles to produce continuous, low grade forces over long periods of time. </li></ul><ul><li>Focus on reversing muscle atrophy . </li></ul><ul><li>Segmental stabilization retraining to protect and support individual segments, and enhance muscle control. </li></ul><ul><li>Address motor control impairments identified in the inner unit. Motor control = pain control. </li></ul>
  22. 22. <ul><li>To cognitively activate the deep stabilizing muscles of the inner unit as independently as possible from superficial muscle activation of the outer unit. </li></ul><ul><li>Drawing in the lower abdominal wall is the specific motor learning task for the transversus abdominis. </li></ul><ul><li>Swelling the deep muscle fibers on either side of the lumbar spine is the task for the lumbar multifidus. </li></ul><ul><li>Contraction of transversus abdominis must be independent of other abdominal muscles. </li></ul><ul><li>Contraction of deep fibers of the multifidus must be independent of erector spinae muscles so that the deep muscle fibers of the multifidus may be emphasized over the superficial. </li></ul>
  23. 23. <ul><li>Peter O’Sullivan, PT, PhD ; uses a motor learning model to describe his exercise progression. Early training starts with the cognitive stage (isolate co-contraction of local muscle system without global muscle substitution). Associative stage is the second phase, where the focus is on refining a particular movement pattern. Finally, the third stage is the autonomous stage where a low degree of attention is required for the correction performance of the motor task. </li></ul><ul><li>Paul Hodges, PhD, PT ; describes a motor learning model starting with the cognitive stage , then the associative stage , and finally the automatic stage (instead of O’sullivan’s autonomous stage). He states that the “level of feedback changes as the rehabilitation progresses through stages.” </li></ul><ul><li>Mark Comerford, PT ; suggests four priorities . Although similar to O’Sullivan’s three stages, Comerford brings new insight into the progression of these specific exercises. ” </li></ul>
  24. 24. <ul><li>Danneels et al 2003 : compared the motor re-education model against two variations of a traditional strengthening model (strength training utilizing concentric and eccentric lumbar extensor loading motions and static (isometric) component which was to be maintained between the concentric and eccentric phases of the exercise); concluding that in order to correct atrophy in lumbar multifidus patients should perform strengthening exercises targeting the lumbar extensors, ideally incorporating an isometric “pause” into the exercise. </li></ul><ul><li>Koumantakis et al 2005 : examined the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with sub-acute or chronic nonspecific back pain by comparing a specific muscle stabilization enhanced general exercise approach with a general exercise only approach; concluding that general trunk exercises alone may be better suited for patients with recurrent episodes of nonspecific sub-acute or chronic LBP but without any overt signs or symptoms of instability. </li></ul>
  25. 25. <ul><li>Kofotolis et al 2006 : This study was to examine the effects of 2 proprioceptive neuromuscular facilitation (PNF) programs on trunk muscle endurance, flexibility, and functional performance in subjects with chronic low back pain (CLBP). Conclusion; the application of 4-week rhythmic stabilization training (RST) and combination of isotonic (COI) PNF programs increased the muscle endurance of people with CLBP by 23.6% to 81%. Back pain intensity and functional disability also decreased significantly. These results suggest that short-term programs with dynamic or static PNF exercises are particularly effective in improving trunk muscle endurance and mobility as well as in reducing back pain symptoms and improving functional performance in people with CLBP. Because the COI group showed greater improvements, the use of dynamic PNF exercises for the management of CLBP appears to be more effective. The resulting changes appeared to last for a period of 2 months after training. </li></ul>
  26. 26. <ul><li>Mengiardi et al 2006 : This study evaluated the fat content of paraspinal muscles by using proton magnetic resonance (MR) spectroscope in patients with chronic low back pain (LBP) and in asymptomatic volunteers matched with regard to age, sex, and body mass index. Concluding that a significantly higher fat content in the multifidus muscle in patients with chronic LBP than in asymptomatic volunteers. No difference was detected with a semiquantitative grading system. </li></ul>
  27. 27. LMS = local muscle system: MANUAL THERAPY (2000) 5 (1), 2-12
  28. 28. <ul><li>Dysfunction of the local systems results in motor control deficit associated with delayed timing, or recruitment deficiency. These muscles react to pain and pathology with inhibited firing patterns. (Hodges PW, Richardson CA. /contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997;77:132-144) </li></ul><ul><li>When rigidity is produced in the lumbar spine, there is evidence to suggest and increase in spinal compression……evidence would suggest that training of the global system may not be the optimal starting point for people who have low back pain. (Dolan P. Associations between mechanical loading spinal function and low back pain. Third Interdisciplinary World Congress on Low Back and Pelvic Pain. 1998; 15-28) </li></ul><ul><li>The pre-contraction of the intrinsic musculature can become delayed or inhibited in the presence of pain or pathology. This delay, or inhibition of the stability system, decreases a patient’s ability to control a joint neutral position during movement or under load. This can also be described as spinal instability. (Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disorders. 1992;5:390-397) </li></ul><ul><li>Deep lumbar multifidus attaches directly to each segment of the lumbar spine. Multifidus contributes to segmental stiffness as a hydraulic amplifier. It also contributes to the control of joint neutral position and increased spinal stiffness. (Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1983;18:568-574) </li></ul>
  29. 29. <ul><li>Patients who showed multifidus muscle pathology were also the majority of the patients who had poor outcomes from surgery. Consequently, patients not showing multifidus pathology had the better outcomes. (Ratanen J, Hurme M, Falck B, et al. The lumbar multifidus muscle five years after surgery for lumbar intervertebral disc herniation. Spine 1983; 18:568-574) </li></ul><ul><li>There was a definite loss of segmental motor control in acute first episode unilateral low back pain patients. These and other works suggest deep lumbar multifidus is directly effected in patients who have low back pain. (Hides JA, Richardson CA, Jull GA. Multifidus recovery is not automatic following resolution of acute first episode low back pain. Spine 1996; 20:2763-2769) </li></ul><ul><li>In recent published studies, segmental attachment of psoas has been shown to decrease in cross-sectional area at the level of confirmed disc herniation by MRI. (Dangaria TR, Naesh O. Changes in cross-sectional area of psoas major muscle in unilateral sciatica caused by disc herniation. Spine 1998; 23:928-931) </li></ul><ul><li>When a patient requires rigidity under load, they must be trained to function under those conditions, but the vast majority of patients who experience low back pain need an intrinsic retraining program first to ensure control of the joint neutral position. (Richardson CA, Jull GA. Muscle control – pain control. What wxercises would you prescribe? Manual Therapy. 1995;1:2-10) </li></ul>
  30. 30. <ul><li>Type I fiber pathologies must be addressed prior to strengthening and endurance exercises. </li></ul><ul><li>Spinal exercise sessions should be performed at least 3 times per week with optimal results performed daily. </li></ul><ul><li>“ No pain-no gain” axiom does not apply when exercising spinal segments. </li></ul><ul><li>Cardiovascular training proves to be effective for rehabilitation and injury prevention for patients living with spinal injury. </li></ul><ul><li>Intervertebral disks are more hydrated early in the morning; avoid performing full-range spinal motions shortly after rising from bed. </li></ul><ul><li>More repetitions of less demanding exercises will assist in the enhancement of “endurance” and “strength”. </li></ul><ul><li>Evidence indicates that “endurance” has more protective value than “strength”. </li></ul><ul><li>Science cannot evaluate the optimal exercises for each situation; the combination of science & clinical experience should be utilized to enhance back health. </li></ul>
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  32. 32. <ul><li>Visit </li></ul>
  33. 33. Roger James Meade, PT