In 3 sentences: Physical therapists Gretchen Leff and Lauren Jarmusz presented on the physical therapy approach to spine care. They discussed using a movement systems framework to assess for impairments in mobility, motor control, and functional movement patterns. Treatment focuses on addressing impairments through local mobility interventions to improve neural, joint and soft tissue mobility, followed by global stability training to develop proper muscle activation, coordination and application to functional skills.

1. PHYSICAL THERAPY APPROACH TO SPINE CARE
MAY 1ST 2019
PM&R GRAND ROUNDS
STANFORD HEALTHCARE
GRETCHEN LEFF, DPT, MSPT, OCS
LAUREN JARMUSZ, DPT, OCS

2. OBJECTIVES
1. Philosophy and Vision of Physical Therapy Profession
2. Movement System: Pathokinesiological vs Kinesiopathological
3. Framework for PT Movement Assessment c Case Examples
4. PT Interventions/ Plan of Care
5. PMR & PT collaboration of care efforts / Referrals PT PM&R

3. PHILOSOPHY & VISION OF
PHYSICAL THERAPY
PROFESSION

4. ROLE OF PHYSICAL THERAPISTS

5. APTA
“The physical therapy
profession
will transform society
by optimizing
movement to improve
the human experience.”

6. GUIDING PRINCIPLES
OF VISION
STATEMENT
“The physical therapy profession’s greatest
calling is to maximize function and
minimize disability for all people of all
ages.
In this context, movement is a key to
optimal living and quality of life for all
people of all ages that extends beyond
health to every person’s ability to
participate in and contribute to society.”

7. MOVEMENT SYSTEM

8. MOVEMENT
SYSTEM
“The movement
system is a
physiological system
that functions to
produce motion of
the body as a whole
or of its component
parts.
The functional
interaction of
structures that
contribute to the act
of moving”.

9. MODELS OF MOVEMENT IMPAIRMENTS
Pathokinesiological
Pathology
Movement
Impairmen
t
Kinesiopathological
Poor
Lumbar
Flexion
Patterning
Pain
Disc
Herniation
Pain
Movement
Impairmen
t
Pathology

10. FRAMEWORK OF PT
EVALUATION

11. SOAP
Subjective
- Patient history
- Systems review/
clearance
Objective
- Standardized
tests and
measures
- Outcome scores
-Traditional
orthopedic tests
- Functional
movement
analysis
- prn- systems
specific clearance
testing
Assessment
- Synthesis of
clinical data
- Determining
primary source of
pain and/or
movement
dysfunction
Plan
- PT intervention
plan of care

12. ORTHOPEDIC TESTING OF SPINE WITHIN CONCEPT OF ‘REGIONAL
INTERDEPENDENCE’
When PT’s treat
“the spine”, we are
treating the entire
MOVEMENT
SYSTEM.

13. FUNCTIONAL MOVEMENT ANALYSIS
MODE:
VISUAL OR TECHNOLOGY ASSISTED
OBSERVATION OF SPINAL MOVEMENT AND
FUNCTIONALLY RELEVANT TASKS
GOAL:
TO IDENTIFY A PATTERN IN MOVEMENT THAT
CONSISTENTLY REPRODUCES PT’S SX AND
UPON MODIFICATION OF PROVOCATIVE
MOVEMENT, THE PT’S SX IMPROVE

14. SOAP
Subjective
- Patient history
- Systems review/
clearance
Objective
- Standardized
measures
- Outcome scores;
Traditional
orthopedic tests
- Functional
movement
analysis
- prn- systems
specific clearance
testing
Assessment
- Synthesis of
clinical data
- Determining
primary source of
pain and/or
movement
dysfunction
Plan
- PT intervention
plan

15. SYNTHESIS OF CONTRIBUTING FACTORS TO MOVEMENT
DYSFUNCTION
Structural
Anatomy
Muscle Performance
Imbalance
Muscle length
Imbalance
Relative Flexibility
Neuromuscular
Patterns/Motor Control

16. RELATIVE FLEXIBILITY

17. ALTERED RECRUITMENT PATTERNS/TIMING ISSUES
 Extension Rotation Movement
Dysfunction
 Interventions
 Address impairments of
strength/ROM if any
 Must address faulty recruitment
and movement patterns

18. MOVEMENT DYSFUNCTIONS OF LUMBAR SPINE
Extension Dysfunction
 Spinal Stenosis
 Mobility dysfn at hip or thoracic
spine
 Excessive extension movement at L
spine
 Rx: Mobilize hip/thoracic spine
while controlling L movement
 Spondylolisthesis
 Younger or degenerative
 Motor Coordination or stability
dysfn – moves more readily at L
spine than hips
 Rx: Upregulate abs for
Flexion Dysfunction
 HNP or Muscle Strain
 Hip Joint Hypomobility
 Mobility issue but not at L
spine
 Hamstring stiffness/shortness
 Spine moves more readily
than hips
Rotation Dysfunction
 Unilateral spondylosis
 Baseball player – limited hip IR

19. PT INTERVENTIONS/ PLAN OF CARE

20. SOAP
Subjective
- Patient history
- Systems review/
clearance
Objective
- Standardized
measures
- Outcome scores;
Traditional
orthopedic tests
- Functional
movement
analysis
- prn- systems
specific clearance
testing
Assessment
- Synthesis of
clinical data
- Determining
primary source of
pain and/or
movement
dysfunction
Plan
- PT intervention
plan

21. Based off the work of Vladimir Yanda.; Adapted by M. Jeanfavre, DPT, OCS,

22. Local Mobility
ensures that
the lumbar
spine and
adjacent joints
independently
possess
adequate
neural, joint,
and soft tissue
mobility
Global Stability
ensures that the
muscles of the
lumbar spine
and in regions
can meet
activation,
acquisition, and
assimilation
needs of lumbar
spine

24. LOCAL MOBILITY INTERVENTIONS
Local Mobility
ensures that
the lumbar
spine and
adjacent joints
independently
possess
adequate
neural, joint,
and soft tissue
mobility
• used to NORMALIZE/IMPROVE
MOTION prior to global stability
training by:
• reducing acute pain
• normalizing/improving:
• soft tissue , joint, nerve mobility
• posture
• proprioception
• Interventions provide TEMPORARY
tissue changes/ pain relief  fixed
changes following global stability

25. SOFT TISSUE
• Static Stretch
• Dynamic Stretch
• Trigger Point Release / Dry Needling
• Active Release
• Instrument Assisted Soft Tissue
Mobilization
• Strain Counter Strain
• Myofascial Decompression
• Pin & Stretch
• Muscle Energy Techniques
• Etc….
Local Mobility
ensures that the
lumbar spine and
adjacent joints
independently
possess adequate
neural, joint, and
soft tissue mobility

26. JOINT
Local Mobility
ensures that the
lumbar spine and
adjacent joints
independently
possess adequate
neural, joint, and
soft tissue mobility
1. Joint
Mobilizations &
Distractions
• Cervical
• Thoracic
• Lumbar
• Hip
• SI
• Ankle
2. AAROM Self
Joint

27. NERVE
Local Mobility
ensures that the
lumbar spine and
adjacent joints
independently
possess adequate
neural, joint, and
soft tissue mobility
Neurodynamic Testing
Lower Extremity
• SLR (sciatic n.)
• Slump
• Femoral n. Stretch
Test
Upper Extremity
• Upper Limb Tension
Tests
• Median
• Ulnar
Neurodynamic
Interventions
• Nerve glides
• Nerve Tensioners
• Desensitization
Techniques

29. ACTIVATION:
GETTING THE RIGHT MUSCLE TO ACTIVATE AT THE RIGHT TIME
Global Stability
ensures that the
muscles of the
lumbar spine and in
regions can meet
activation,
acquisition, and
assimilation needs
of lumbar spine
TECHNIQUES:
• Tactile Cuing
• Verbal Cuing
• Visual Feedback
• Biofeedback
• Neuromuscular Electrical Stimulation
(NMES)
• Part Task Neuro Re-education
Patient’s Goal: complete ‘Power Clean’ without LBP
Impairment: “glute max amnesia”; hamstring & paraspinal
activation > glute max & ‘core brace’ activation patterning with
terminal hip extension

30. ACQUISITION:
TRAINING APPROPRIATE COORDINATION OF MOVEMENT
Global Stability
ensures that the
muscles of the
lumbar spine and in
regions can meet
activation,
acquisition, and
assimilation needs
of lumbar spine
TECHNIQUES:
• Part -> Whole Task Neuro
Retraining
• Strength Training (Hypertrophy)
• Muscular Endurance Training
• Video Analysis

31. ASSIMILATION:
APPLYING COORDINATED MOVEMENT TO FUNCTIONAL SKILL
Global Stability
ensures that the
muscles of the
lumbar spine and in
regions can meet
activation,
acquisition, and
assimilation needs
of lumbar spine
TECHNIQUES:
• Sport Specific Training
• FLEE
• Agility & Power Training
• ADL Specific Training
• Work Specific Training

32. Physical Therapists have trialed numerous
classification systems with alternate subgroups of
treatment in order to: apply a standardized PT dx
and treatment to appropriately guide best
practice treatment interventions for spine based
painBut… what does the research
actually say?

33. 1. Acute LBP c Mobility Deficits
2. Subacute LBP c Mobility Deficits
3. Acute LBP c Movement Coordination
Impairments
4. Subacute LBP c Movement
Coordination Impairments
5. Chronic LBP c Movement
Coordination Impairments
6. Acute LBP c Referred Pain
7. Acute LBP c Radiating Pain
LUMBAR SPINE
CLINICAL PRACTICE GUIDELINES
CERVICAL SPINE
CLINICAL PRACTICE GUIDELINES
1. Neck Pain c Mobility Deficits
2. Neck Pain c Movement Coordination
Impairments (WAD)
3. Neck Pain c Headaches
(Cervicogenic)
4. Neck Pain with Radiating Pain
(Radicular)
APTA 2018

34. EXAMPLES LBP
CLASSIFICATION
SYSTEMS
-Karayannis 2016

35. EVIDENCE - CLASSIFICATION SYSTEMS (LBP)
”Perhaps one reason for the variety of subgrouping
schemes lies in the rationale that one assessment
method cannot be applicable to all types of patient
characteristics, or adequately capture the diverse
pool of responses from a single assessment
strategy. In contrast, the broad selection of schemes
may symbolize a beneficial diversity in assessment
viewpoints, or hold insight on proficient and
deficient elements within classification systems.”
-Karayannis 2016
CONCLUSION: No
classification system has been
shown to be superior in
directing LBP PT intervention.

36. EVIDENCE – SUBGROUPS OF TREATMENT
MOTOR CONTROL SPECIFIC EXERCISE VS GENERAL EXERCISE
ie: MSI vs Stabilization TBC
subgroup
which is more effective?
CONCLUSION: Motor control
specific exercises do not
appear to provide additional
benefit to patients with non
specific low back pain.

37. “Surveys of clinicians managing LBP
show that there are strong views
against generic treatment and an
expectation that treatment should be
individualized to the
patient. However, despite this
emphasis on treatment-based sub-
groups, little high-quality evidence
exists for the investigation of
subgroups of patients with LBP
who respond best to specific
interventions.”

38. “There were no differences in function between the two treatment groups
(CS & NCs). In both treatment groups, people with chronic LBP displayed
clinically important long- term improvements in function. When both
forms of adherence were considered, the improvements were uniquely
related to adherence to performance training”
– Van Dillen 2016, RCT, ”Manual Therapy”
ACTIVATION ACQUISION ASSIMILATION SKILL
CONTINUED
REDUCED/
RESOLVED LBP

39. PM&R and PT
COLLABORATION EFFORTS

40. PM&R
Assistance
Managing
PT POC Focus

41. THANK YOU!
Looking forward to working with
the PM&R team to improve
collaborative patient centered
care.

42. CITATIONS

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