terça-feira, 2 de junho de 2015

Management of Osteoporosis of the Spine -- A Clinical Enigma

By R. Vincent Davis, DC, PT, DNBPM

Osteoporosis of the spine involves a reduction in the number and size of bony trabeculae and results in a reduction in the resistance of the vertebrae to physical stresses. The effect of this adverse trabecular change results in spontaneous fracture with deformity and respective pain.
The most prominent changes involve the spine, the ribs, and the components of the pelvis. As the spine responds biomechanically to the effects of vertebral osteoporosis, it slowly, but progressively, presents with a configuration common to kyphoscoliosis. This configuration progresses under the influence of gravity, until it is stopped when the lower ribs come to rest upon the iliac crest bilaterally.

Etiologically, osteoporosis is a product of postmenopausal hypoestrogenism, either physiological or surgical, senility, Cushing's syndrome, cortisone and ACTH treatment, hyperthyroidism, immobilization, and malabsorption osteopenia. Of course, osteoporosis and osteomalacia may coexist. Of course, the most common finding is in the postmenopausal female subject to hypoestrogenism.

Pathologically, the vertebrae become soft and fragile and the centrum in the thoracic region becomes wedge shaped due to anterior compressive forces. In the lumbar region, the superior and inferior surfaces of the centrum becomes indented due to exposure to the expansile forces of the intervertebral discs. Macroscopically, the spine appears as a series of biconcave vertebral bodies possessing increased intervertebral disc spaces. Radiographically, the transverse trabeculations disappear and the vertebral body margins become indistinct. The thoracolumbar junction is a common site for compression fractures of the effected vertebrae.

Clinically, these patients complain of pain in the bones, especially in those of the spine. Such patients exhibit a distinctly rounded thoracic spine, a short stature with a stoop shouldered habitus. Otherwise trivial trauma commonly results in minute fractures which are radiographically unidentifiable. Such an episode of trauma historically is of acute onset, has a point of tenderness consistent with the site of spontaneous fracture and is relieved to some degree by recumbency.

Although treatment for osteoporosis is somewhat controversial, this author recommends the following at a stage of progress early enough in the patients history not to constitute a danger to compression fracture. Daily therapeutic exercise, primarily involving aerobics, with the intention that the exercise will result in gravitational forces along the trabecular stress lines of the vertebral bodies thereby employing the principles of Wolff's law in bone physiology. The patient should be instructed to use a bed board between the mattress and box springs, unless some contraindication exists, which serves the purpose of providing a plannar surface for the spine to conform to biomechanically. Also, this will tend to enhance the density of bone, again in accordance with Wolff's law.

In the presence of a spontaneous vertebral fracture, the patient will have the least pain in a recumbent position to avoid the axial forces of gravity on the spine. Moist heat may be applied to the area of the fracture site to relief pain and spasm. The author recommends the alternate application of pulsed ultrasonic energy in order to complement the effect of Wolff's law relative to the trabecular stress lines without the presence of gravitational forces. Shortwave diathermy is contraindicated. Thoracic hyperextension orthosis may be applied as tolerated by the patient. Swimming is an excellent rehabilitation exercise. Walking, with assistance, is highly recommended as soon as possible with the patient wearing a soft shoe.

Bed rest is recommended only for as long as is necessary to allow the patient sufficient recovery to begin ambulation, which should begin as soon as possible. The following time factors are intended as guidelines for the projected recovery process. Relief of pain should take place within about two weeks. Gradual mobility to amylation should be within about five weeks with therapeutic exercise commencing as soon as pain permits. This author cannot resist the need to mention the oral administration of calcium orotate, 1500 mg daily as a divided dose, b.i.d., the greater portion of this being taken at bed time. In my degree work in nutrition I was impressed with the effectiveness of this salt in treating this metabolic problem. Of course, the patient must ingest a balanced diet daily and must have adequate sunlight exposure to ensure vitamin D conversion.

References

Davis RV: Therapeutic Modalities for the Clinical Health Sciences, 2nd ed., Library of Congress Card #TXU 389-661

Griffin JE and Karselis TC: Physical Agents for Physical Therapists 2nd ed, Springfield: Charles C. Thomas Publishers 1982

Krusen, Kottke, Ellwood: Handbook of Physical Medicine & Rehabilitation, 2nd ed. Philadelphia: W.B. Saunders Company, 1971.

Netter: The CIBA Collection - Musculoskeletal System, Part I.

Schriber WA: A Manual of Electrotherapy, 4th ed. Philadephia: Lea & Febiger, 1975.

Turek: Orthopedics - Their Principles and Application, 3rd ed. Lippincott Publishers

Occipitalization of the Atlas

By Brad McKechnie, DC, DACAN

Occipitalization of the atlas, or atlanto-occipital fusion, is one of the most common skeletal abnormalities of the upper cervical spine. According to Yochum,¹ occipitalization represents the most cephalic "blocked" vertebra encountered in the spine.
The onset of neurological symptoms is usually in the third or fourth decade. Younger patients are commonly asymptomatic. Symptoms usually begin insidiously and progress slowly, although sudden onset and instantaneous deaths have been reported with trauma to the region of the craniocervical junction. Trauma has been implicated as a precipitating factor in at least half of reported symptomatic cases, although symptoms associated with trauma may not be as severe as previously mentioned.

Neurological symptoms associated with occipitalization of the atlas are attributed to ligamentous laxity of the transverse ligament about the odontoid caused by repeated flexion and extension of the neck leading to compression of the spinal cord or actual indentation of the medulla. With aging, the central nervous system may become less tolerant to repeated blows from the odontoid. The presence of blocked vertebrae below this level may accelerate this process due to compensatory motion at the atlantoaxial joint. In a study conducted by McRae,² fusion of C2/C3 was noted in 17 of 25 patients with occipitalization of the atlas. Additionally, symptoms are attributed to abnormal size and a high position of the odontoid process, leading to compression of the spinal cord or medulla.

The patient will probably be asymptomatic if the odontoid process is located below the foramen magnum. This relationship is best assessed through the use of McRae's line, which is drawn across the foramen magnum. Normally the odontoid process should not project above this line. According to Greenberg,³ spinal cord compression always occurs when the sagittal spine canal diameter behind the odontoid process is less than or equal to 14 millimeters. Cord compression is possible when the sagittal canal diameter is between 15 and 17 millimeters, and almost never occurs at a distance of 18 millimeters or more.

Patients with occipitalization of the atlas may have the following physical features: low hairline, torticollis, restricted neck movements, and an abnormally short neck. The presence of these features should alert the chiropractic physician to the possibility of underlying congenital anomalies which may alter the type of manipulative care delivered in the upper cervical region. Neurological examination of the atlanto-occipital fusion patient may reveal the following clinical findings: headache, neck pain, numbness and pain in the limbs, weakness, and an abnormal head posture. The headaches associated with this condition are characterized as dull and aching, and are located over the posterior two thirds of the skull. The headaches may be precipitated by coughing or by neck movements. Long tract signs, associated with dysfunction to the lateral corticospinal tract, may be present in the upper and lower extremities in the form of hyperreflexia, spasticity, Hoffman's sign, and Babinski's sign. Cranial nerve findings associated with occipitalization of the atlas include tinnitus, visual disturbances, lower cranial nerve palsies leading to dysphagia and dysarthria, and downbeat nystagmus. Horner's syndrome has also been reported in association with atlanto-occipital fusion.4 Additionally, the neurological symptoms and signs of atlanto-occipital fusion cannot be distinguished from those of the Arnold-Chiari malformation as the pathophysiology of both is essentially the same. Arnold-Chiari malformations may occur in conjunction with atlanto-occipital fusion. The chiropractic physician encountering a patient with atlanto-occipital fusion should carefully assess the integrity of the upper cervical complex and perform a thorough neurological examination prior to application of regional adjustive procedures.

References

Yochum TR and Rowe LJ: Essentials of Skeletal Radiology, William and Wilkins, Baltimore, 1987.
McRae DL and Barnum AS: Occipitalization of the atlas, AJR, 70:23, 1953.
Greenberg AD: Atlanto-axial dislocations, Brain, 91:655, 1968.
Hensinger RN: Atlanto-occipital fusion in Cervical Spine Research Society, The Cervical Spine, J.B. Lippincott, Philadelphia, 1983.

Facet joint sprain

Causes of sciatica

What is a facet joint sprain?

The spine comprises of many bones known as vertebrae. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the discs centrally (figure 1). These joints are designed to support body weight and enable spinal movement.

Each facet joint comprises of smooth cartilage which lies between the bony joint surfaces cushioning the impact of one bone on another. Strong connective tissue also wraps around the bony ends providing support to the joint.During certain movements of the spine, stretching or compressive forces are placed on the facet joint. If these forces are excessive and beyond what the facet joint can withstand, injury to the facet joint may occur. This may involve damage to the cartilage or tearing to the connective tissue surrounding the joint. This condition is known as a facet joint sprain.

Figure 1 - Relevant Anatomy for a Facet Joint Sprain

Causes of a facet joint sprain

Facet joint sprains typically occur during excessive bending (i.e. forwards, backwards or sideways), lifting or twisting movements. They may occur traumatically or due to repetitive or prolonged forces.

Signs and symptoms of a facet joint sprain

Patients with this condition may experience a sudden onset of back pain during the causative activity. However, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning. Symptoms are typically felt on one side of the spine and muscle spasm may be experienced around the affected joint. Occasionally pain may be referred into the buttock or lower limb on the affected side. Symptoms are generally exacerbated with activities that involve twisting, lifting, arching backwards, bending forwards or sideways or sitting for prolonged periods of time.

Diagnosis of a facet joint sprain

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a facet joint sprain. Investigations such as an MRI or CT scan may be required to confirm diagnosis.

Prognosis of a facet joint sprain

The recovery time for a facet joint sprain may vary from patient to patient depending on compliance with physiotherapy. With ideal treatment, patients may be pain free in as little as several days, although typically this may take 2 – 3 weeks. It is important to note, however, that injured tissue takes approximately six weeks to restore the majority of its strength in ideal healing conditions. Care must therefore be taken when returning to activity during this period.

Physiotherapy for a facet joint sprain

Physiotherapy for a sprained facet joint can hasten the healing process, ensure an optimal outcome and minimise the likelihood of future recurrence. Treatment may comprise:

soft tissue massage
electrotherapy (e.g. ultrasound)
mobilization
manipulation
dry needling
postural taping
the use of a back brace
the use of a lumbar roll for sitting
education
activity modification advice
biomechanical correction
ergonomic advice
clinical Pilates
hydrotherapy
exercises to improve flexibility, strength, posture and core stability
a gradual return to activity program

Contributing factors to the development of a facet joint sprain

There are several factors that may contribute to the development of a facet joint sprain. These factors need to be assessed and corrected with direction from a physiotherapist and may include:

poor posture
lumbar spine stiffness
a sedentary lifestyle
poor core stability
muscle weakness or tightness
muscle imbalances
inappropriate lifting technique
being overweight
biomechanical abnormalities
a lifestyle involving large amounts of sitting, bending or lifting

Other intervention for a facet joint sprain

Despite appropriate physiotherapy management, a small percentage of patients with a sprained facet joint fail to improve and may require other intervention. This may include pharmaceutical intervention, investigations such as an X-ray, CT scan or MRI, or assessment from a specialist. A corticosteroid injection into the facet joint may sometimes be used to help alleviate symptoms. The treating physiotherapist or doctor can advise on appropriate management and can refer to the appropriate medical authority if it is warranted clinically.

Exercises for a facet joint sprain

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercises

Transversus Abdominus Retraining

Slowly pull your belly button in "away from your belt line" and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 3). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.

Figure 3 – Transversus Abdominus Retraining

Rotation in Lying

Begin this exercise lying on your back as demonstrated (figure 4). Slowly take your knees from side to side as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.

Figure 4 – Rotation in Lying

Elbow Prop

Begin lying on your front (figure 5). Slowly move up onto your elbows provided there is no increase in symptoms. Hold this position for 2 seconds and then return to lying flat. Repeat 10 times provided the exercise is pain free.

Figure 5 – Elbow Prop

Hip Flexion

Slowly take your knee towards your chest as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 6). Use your hands to gently bring your knee closer to your chest. Repeat 5 - 10 times on each leg provided there is no increase in symptoms.

Figure 6 – Hip Flexion

Sacroiliac joint dysfunction

Causes of sciatica

What is sacroiliac joint dysfunction?

The sacroiliac joint is located in the lower part of the back and joins the tail bone (sacrum) to one of the pelvic bones (ilium). There are two sacroiliac joints – one on either side of the spine (figure 1). The sacroiliac joints act to transfer weight from the spine to the pelvis and allow a small amount of movement to occur.

During certain movements of the spine and hips, stretching or compressive forces are placed on the sacroiliac joints and surrounding ligaments. If these forces are excessive and beyond what the sacroiliac joint can withstand, injury to the sacroiliac joint may occur. This is known as sacroiliac joint dysfunction.

Causes of sacroiliac joint dysfunction

Sacroiliac joint dysfunction may occur from excessive forces being applied to the sacroiliac joint. This can be from bending, sitting, lifting, arching or twisting movements of the spine, or, from weight bearing forces associated with running or jumping. Injury to the sacroiliac joint may occur traumatically or due to repetitive or prolonged forces over time.

Signs and symptoms of sacroiliac joint dysfunction

Patients with this condition usually experience one sided low back pain around the top of the buttock with symptoms sometimes referring into the lower buttock, groin or thigh. In rare cases, pain may be felt on both sides of the lower back. Symptoms are generally exacerbated with activities that involve lower back or hip movements. Often patients will experience pain upon rolling over in bed, putting on or taking off their shoes and socks, walking up and down stairs, or with running. Tenderness is usually felt on firm palpation of the sacroiliac joint. Sacroiliac joint dysfunction may also be associated with asymmetry of the pelvis due to muscle tightness, joint stiffness, or joint laxity associated with pregnancy.

Diagnosis of sacroiliac joint dysfunction

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose sacroiliac joint dysfunction. Investigations such as an X-ray, MRI, bone scan or CT scan may be used to assist with diagnosis.

Prognosis of sacroiliac joint dysfunction

The recovery time for sacroiliac joint dysfunction may vary from patient to patient depending on compliance with physiotherapy. With ideal treatment, patients may be pain free in as little as several days, although typically this may take 2 – 3 weeks. It is important to note, however, that injured tissue takes approximately six weeks to restore the majority of its strength in ideal healing conditions. Care must therefore be taken when returning to activity during this period.

Physiotherapy for sacroiliac joint dysfunction

Physiotherapy treatment for sacroiliac joint dysfunction can hasten healing, ensure an optimal outcome and reduce the likelihood of future recurrence. Treatment may comprise:

soft tissue massage
mobilization
manipulation
electrotherapy (e.g. ultrasound)
taping
the use of a sacroiliac belt or lumbar brace
the use of a lumbar roll for sitting
correction of any leg length discrepancy
dry needling
muscle energy techniques
education
activity modification advice
biomechanical correction
ergonomic advice
clinical Pilates
hydrotherapy
exercises to improve flexibility, strength, posture and core stability
a gradual return to activity program

Contributing factors to the development of sacroiliac joint dysfunction

There are several factors that may contribute to the development of sacroiliac joint dysfunction. These factors need to be assessed and corrected with direction from a physiotherapist and may include:

muscle imbalances
leg length differences
muscle weakness or tightness
biomechanical abnormalities
poor posture
lumbar spine stiffness
a sedentary lifestyle
poor core stability
inappropriate lifting technique
being overweight
a lifestyle involving large amounts of sitting, bending or lifting

The pelvic girdle changes associated with pregnancy may also contribute to the development of sacroiliac joint pain.

Other intervention for sacroiliac joint dysfunction

Despite appropriate physiotherapy management, a small percentage of patients with sacroiliac joint dysfunction fail to improve and may require other intervention. This may include pharmaceutical intervention, investigations such as an X-ray, bone scan, CT scan or MRI, blood tests or assessment from a specialist. A corticosteroid injection into the sacroiliac joint may sometimes be used to help alleviate symptoms. In those patients with poor foot biomechanics, review with a podiatrist may be indicated for potential orthotics. The treating physiotherapist can advise on appropriate management and can refer to the appropriate medical authority if it is warranted clinically.

Exercises for sacroiliac joint dysfunction

Initial Exercises

Transversus Abdominus Retraining

Figure 3 – Transversus Abdominus Retraining

Rotation in Lying

Begin this exercise lying on your back as demonstrated (figure 4). Slowly take your knees from side to side as far as possible and comfortable provided there is no increase in symptoms. Repeat 10 times.

Figure 4 – Rotation in Lying

Elbow Prop

Figure 5 – Elbow Prop

Hip Flexion

Slowly take your knee towards your chest as far as possible and comfortable without pain (figure 6). Use your hands to gently bring your knee closer to your chest. Repeat 5 - 10 times on each leg provided there is no increase in symptoms.

Figure 6 – Hip Flexion

Piriformis syndrome

Causes of sciatica

What is piriformis syndrome?

Piriformis syndrome is a relatively uncommon cause of buttock pain and sciatica. The piriformis muscle lies deep within the buttock originating from the sacrum (tail bone) and attaching to the femur (thigh bone) (figure 1).

The piriformis muscle is responsible for rotating and stabilizing the hip joint. The sciatic nerve passes directly beneath or occasionally through the piriformis muscle (figure 1). Due to this anatomic relationship, the sciatic nerve can be compressed due to tightness in the piriformis muscle or following a piriformis strain. When this occurs the condition is known as piriformis syndrome.

Causes of piriformis syndrome

Piriformis syndrome typically occurs due to tightness of the piriformis muscle. This may occur following piriformis injury, overuse of the piriformis, injury to the lumbar spine or due to repetitive strain or trauma. Piriformis syndrome is more common in sports or activities requiring repeated use of the piriformis muscle. These activities may include: running (especially changing direction), sprinting, jumping, squatting or lunging.

Signs and symptoms of piriformis syndrome

Patients with this condition typically experience a pain or ache that is felt deep within the buttock. Pain may also radiate into the back of the thigh, calf, ankle or foot. Patients with piriformis syndrome typically experience an increase in pain when placing the piriformis muscle on stretch (i.e. taking your knee towards your opposite shoulder) or during forceful piriformis muscle contraction (e.g. when running and changing directions). Other activities that may aggravate symptoms include: sitting, climbing stairs, squatting and lunging. In addition, patients may also have reduced hip range of movement and experience tenderness in the piriformis muscle on firm palpation.

Diagnosis of piriformis syndrome

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose piriformis syndrome. Occasionally, further investigations such as an MRI scan or Ultrasound may be required, to assist diagnosis.

Prognosis of piriformis syndrome

With early diagnosis and appropriate management, most patients with this condition can usually recover in days to weeks. In severe or chronic cases of piriformis syndrome, recovery may take significantly longer.

Contributing factors to the development of piriformis syndrome

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

muscle tightness (particularly the piriformis and adductor muscles)
joint stiffness (particularly the hip, lower back, sacroiliac joints or pelvic joints)
muscle weakness (particularly the piriformis and gluteals)
lower back injury
poor posture
excessive or inappropriate training
poor biomechanics
inadequate warm up
poor pelvic or core stability
muscle imbalances

Physiotherapy for piriformis syndrome

Physiotherapy for patients with this condition is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may comprise:

soft tissue massage
electrotherapy (e.g. ultrasound)
stretches
dry needling
muscle energy techniques
joint mobilization
neural mobilization
ice or heat treatment
education
biomechanical correction
progressive exercises to improve strength, flexibility and core stability
activity modification advice
technique correction
devising and monitoring a return to sport or activity plan

Other intervention for piriformis syndrome

Despite appropriate physiotherapy management, some patients with this condition do not improve adequately. When this occurs, the treating physiotherapist or doctor can advise on the best course of management. This may include investigations such as an ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid injection, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition. In very rare cases of severe or recalcitrant piriformis syndrome, surgical intervention may be considered.

Exercises for piriformis syndrome

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercise and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercise

Piriformis Stretch Supine

Begin lying on your back (figure 2). Using your hands, take your knee towards your opposite shoulder until you feel a stretch in the buttocks or front of your hip. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided the exercises is pain free.

Figure 2 – Piriformis Stretch (right leg)

Spondylolisthesis

Causes of sciatica

What is a spondylolisthesis?

The spine comprises of many bones known as vertebrae. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally (figure 1). These joints are designed to support body weight and enable spinal movement.

A spondylolisthesis refers to the slipping of one vertebra forward on another. This typically occurs due to defects in the bone which usually develop during childhood and is most commonly seen in children between the ages of 9 and 14. The defect is due to an absence of a section of bone on each side of the vertebral column which assists in holding the vertebra in alignment. This section of bone is known as the 'pars interarticularis' (figure 1). Although uncommon, a spondylolisthesis may also occur due to stress fractures in each pars interarticularis. This may occur due to excessive athletic or sporting activity involving repetitive hyperextension of the spine.

A spondylolisthesis is graded according to the degree of slip of the vertebra relative to the vertebra below. A Grade I slip indicates a slip of less than 25%, Grade II – 50%, Grade III – 75% and Grade IV > 75%.

Signs and symptoms of a spondylolisthesis

Patients with this condition generally experience an increase in pain during activities that straighten or extend the spine (figure 2), especially if these activities are repetitive, excessive, or, maintained for long periods of time. Conversely, activities that bend the spine (e.g. sitting) tend to ease symptoms. It is important to note, that many patients with a Grade I spondylolisthesis may experience no symptoms and be completely unaware of the defect. Patients with a Grade II spondylolisthesis or higher, however, more commonly experience lower back pain with or without associated leg pain.

Diagnosis of a spondylolisthesis

X-ray investigation is usually required to confirm diagnosis of a spondylolisthesis. This is best performed in the position that reproduces the patient's pain.

Treatment for a spondylolisthesis

Treatment of patients with this condition is determined by the severity of symptoms and grade of injury. Typically, treatment involves rest from aggravating activity combined with abdominal and lower back strengthening exercises. Once the patient is pain-free, a gradual increase in activity and exercise can occur provided symptoms do not increase. Wearing an appropriate brace during activity may be helpful. If symptoms do recur upon resuming sport, then that activity should be ceased. Patients with a Grade III or IV spondylolisthesis should avoid high speed or contact sports altogether.

Alternative exercises placing minimal force through the lower back should also be performed to maintain fitness provided they do not increase symptoms. Better activities include: cycling, cross trainer, rowing, water running and clinical Pilates. Patients should also perform flexibility, strengthening and core stability exercises to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Contributing factors to the development of symptoms of a spondylolisthesis

There are several factors that may contribute to the development of symptoms in patients with this condition. These need to be assessed and corrected with direction from a physiotherapist and may include:

poor posture
poor core stability
muscle weakness
poor flexibility
joint stiffness

Technique adjustment should also be made to restrict the amount of extension during sporting activity.

Physiotherapy for a spondylolisthesis

Physiotherapy treatment for patients with this condition is vital to hasten the healing process and ensure a safe return to activity. Treatment may comprise:

soft tissue massage
electrotherapy (e.g. ultrasound)
bracing
mobilization
dry needling
education
activity modification advice
biomechanical correction
clinical Pilates
hydrotherapy
exercises to improve flexibility, strength and core stability
a gradual return to activity program

Other intervention for a spondylolisthesis

Despite appropriate physiotherapy management, a small percentage of patients with this condition fail to improve adequately or deteriorate. When this occurs, other intervention may be required. This may include further investigations such as X-rays, CT scan or MRI, or assessment from a specialist. Although it is rare for a slip to progress, spinal fusion surgery may be indicated if there is evidence of progression. The treating physiotherapist can advise if this may be required and can refer to the appropriate medical authority if it is warranted clinically.

Exercises for a spondylolisthesis

Rotation in lying

Begin this exercise lying on your back, knees bent, feet flat and together as demonstrated (figure 4). Gently take both knees from side to side as far as possible and comfortable without increasing your symptoms. Repeat 10 times.

Figure 4 – Rotation in lying

Knees to chest

Begin this exercise lying on your back with your knees bent as demonstrated (figure 5). Take both knees towards your chest as far as possible and comfortable provided there is no increase in symptoms. Repeat 10 times.

Figure 5 – Knees to chest

Spinal canal stenosis

Causes of sciatica

What is spinal canal stenosis?

Spinal canal stenosis is a condition characterised by narrowing of the space in the spine primarily responsible for housing the spinal cord (known as the spinal canal or vertebral canal). It is most commonly caused by age-related changes to the spine.

The spine comprises of many bones known as vertebrae each of which has a large hole in its centre (figure 1). Because these bones are situated on top of each other, their holes line up, forming the spinal canal. This canal provides protection and space for the spinal cord and nerves to travel from the brain to the rest of the body. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally (figure 2).

Vertebral Anatomy for Spinal Canal Stenosis

Figure 1 - Vertebra

Figure 2 - The Spine

Over time, gradual wear and tear to the discs, joints and bones of the spine can occur resulting in degenerative changes to the spine. These degenerative changes may include osteoarthritis, reduced disc height, disc bulging or protrusion, loss of joint cartilage, bony spurring (osteophytes), thickening of ligaments or bone and vertebral slipping or malalignment. Some of these changes may also occur following trauma or due to a specific incident (e.g. a bulging disc). When these or other changes, in isolation or combination, result in narrowing of the spinal canal, the condition is known as spinal canal stenosis. As the condition progresses, the narrowing may place pressure on the spinal cord resulting in a variety of symptoms.

Whilst spinal stenosis can occur at any age, it is most common in those who are greater than 60 years of age.

Causes of spinal canal stenosis

Spinal canal stenosis is a condition that often occurs over time due to gradual wear and tear associated with overuse or aging. It may be particularly common in patients with a history of lower back pain or trauma to the spine or in those with sedentary lifestyles or lifestyles that have involved large amounts of lifting, bending, twisting or sitting activities.

Spinal Canal Stenosis may also commonly occur over a shorter period of time due to a specific incident or following repetitive or prolonged sitting, bending, lifting or twisting forces. In these instances, damage to an intervertebral disc may occur causing the disc material to bulge or herniate into the spinal canal (see Lumbar Disc Bulge).

Occasionally this condition may occur following traumatic injuries, such as a motor vehicle accident resulting in vertebral fractures or dislocations, or less commonly, due to other space occupying lesions, such as tumours or cysts.

In a small percentage of patients, hereditary factors such as congenital narrowing of the spinal canal, or forward slipping of one vertebrae on another (Spondylolisthesis) may be present at birth increasing the likelihood of the condition developing.

Below is a list of some of the most common factors which may in isolation or combination cause the spaces in the spinal canal to narrow:

Disc bulging or protrusion
Osteoarthritis of the spine (Spinal Degeneration)
Bony spurring (osteophytes)
Thickening of ligaments
Vertebral malalignment or slipping (Spondylolisthesis)
Facet Joint degeneration
Rheumatoid arthritis
Spinal fractures or dislocations
Spinal tumours or cysts

It is important to diagnose the precise cause of the spinal canal stenosis, as treatment for the various conditions or causes can differ markedly.

Signs and symptoms of spinal canal stenosis

Spinal canal stenosis is most commonly seen in older patients who have degenerative changes to their spine. Patients with minor canal stenosis may experience little or no symptoms. As the condition progresses patients may begin to experience lower back pain, ache and / or stiffness. In more severe cases involving spinal cord compression, severe pain, muscle spasm, shooting pain, pins and needles, weakness, numbness or burning sensations may be experienced in the lower back, buttocks, legs or feet.

Generally, patients with this condition experience an increase in symptoms during activities that repetitively or continuously straighten or extend the spine (figure 3). Symptoms may also increase during activities that place weight on the spine (e.g. lifting, prolonged standing, walking etc.). Symptoms tend to ease during activities that bend the spine (e.g. sitting) or take weight off it (e.g. lying down).

In patients who have spinal canal stenosis secondary to a lumbar disc bulge, the condition may have an almost opposite response to movement patterns, with symptoms typically deteriorating during prolonged or repetitive sitting or bending forwards activities and improving with activities that straighten or extend the spine. For more information see Lumbar Disc Bulge.

Figure 3 - Spinal Extension

Diagnosis of spinal canal stenosis

A thorough subjective and objective examination from an experienced physiotherapist combined with appropriate investigations such as an X-Ray, CT scan or MRI are usually required to confirm diagnosis of spinal canal stenosis and determine the underlying cause of symptoms.

Prognosis of spinal canal stenosis

Although little can be done to reverse the degenerative changes to the spine commonly associated with this condition, most patients can have a good outcome with appropriate management. Many patients with mild to moderate degenerative changes and spinal stenosis can often experience little or no symptoms with appropriate management and remain active with some lifestyle modifications. Patients with more severe stenosis can also demonstrate significant improvements with appropriate management, although typically, they may require more significant lifestyle modifications and often experience more severe symptoms and functional limitations.

Physiotherapy for spinal canal stenosis

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Contributing factors to the development of spinal canal stenosis

There are several factors that may contribute to the development of this condition. These factors need to be assessed and where possible, corrected with direction from a physiotherapist and may include:

age (> 40 years)
a lifestyle that has involved large amounts of lifting, sitting, bending or twisting
history of injury or trauma to the lower back
being overweight
excessive or inappropriate activity
inadequate recovery periods from activity
poor posture
lumbar spine stiffness
poor core stability
muscle weakness or tightness
muscle imbalances
a sedentary lifestyle
inappropriate lifting technique
biomechanical abnormalities
hereditary factors
poor diet

Other intervention for spinal canal stenosis

Despite appropriate physiotherapy management, some patients with this condition continue to deteriorate. When this occurs, other intervention may be required. This may include pharmaceutical intervention, investigations such as an X-ray, CT scan or MRI, corticosteroid injection, the use of supplements such as glucosamine, chondroitin or fish oil, or assessment from a sports doctor, orthopaedic specialist or neurosurgeon. The treating physiotherapist can advise on appropriate management and can refer to the appropriate medical authority if it is warranted clinically. In more severe cases of spinal canal stenosis surgery may be required to relieve the pressure on the spinal cord.

Exercises for spinal canal stenosis

The following exercises are commonly prescribed to patients with this condition secondary to spinal degeneration and associated changes (such as disc narrowing, facet degeneration, bony spurring and thickening of ligaments and bone). You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should only take place provided there is no increase in symptoms.

For appropriate exercises for spinal stenosis secondary to a herniated or bulging disc or spondylolisthesis, please see the relevant link below:

Initial Exercises

Transversus Abdominus Retraining

Slowly pull your belly button in "away from your belt line" and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 4). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.

Figure 4 – Transversus Abdominus Retraining

Rotation in Lying

Begin this exercise lying on your back as demonstrated (figure 5). Slowly take your knees from side to side as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.

Figure 5 – Rotation in Lying

Spinal degeneration

Causes of sciatica

What is spinal degeneration?

Spinal degeneration is a condition characterised by gradual wear and tear to the discs, joints and bones of the spine that typically occurs in older patients.

Over time, wear and tear to the discs, joints and bones can occur resulting in degenerative changes to the spine. These degenerative changes may include decreased disc height, loss of joint cartilage, bony spurring (osteophytes) and thickening of bone. This condition is known as spinal degeneration. As this condition progress the spinal canal and intervertebral foramen can begin to narrow (leading to spinal canal stenosis) and may eventually place pressure on the spinal cord and nerves resulting in a variety of symptoms.

Figure 1 - Vertebral Anatomy

Figure 2 - Relevant Anatomy for Spinal Degeneration

Causes of spinal degeneration

Spinal degeneration is a condition that typically occurs over time due to gradual wear and tear associated with overuse or aging. It may be particularly common in patients with a history of lower back pain or trauma to the spine or in those with lifestyles that have involved large amounts of lifting, bending, twisting or sitting activities.

Signs and symptoms of spinal degeneration

Spinal degeneration is usually seen in older patients. Minor cases of degeneration may cause little or no symptoms. As the condition progresses patients may experience low back pain, loss of spinal movement and general lower back stiffness. In more severe cases involving spinal cord or nerve compression, pain, pins and needles, weakness or numbness may be experienced in the lower back, buttocks, groin, legs or feet.

Patients who experience pain due to this condition generally experience an increase in symptoms during activities that repetitively or continuously straighten or extend the spine (figure 3). Symptoms may also increase during activities that place weight on the spine (e.g. lifting, prolonged standing, walking etc.). Symptoms tend to ease during activities that bend the spine (e.g. sitting) or take weight off it (e.g. lying down).

Figure 3 - Spinal Extension

Diagnosis of spinal degeneration

A thorough assessment from a physiotherapist combined with appropriate investigations is usually required to diagnose spinal degeneration. An X-ray of the spine will typically demonstrate changes associated with degeneration. Other investigations such as CT scan, bone scan or MRI may also be indicated to assess the severity and to determine the exact structures that are affected.

Prognosis of spinal degeneration

Although little can be done to reverse the degenerative changes to the spine associated with this condition, most patients can have a good outcome with appropriate management. Many patients with mild to moderate degenerative changes to the spine can often experience little or no symptoms with appropriate management and remain active with some lifestyle modifications. Patients with more severe degeneration can also demonstrate significant improvements with appropriate management, although typically, they may require more significant lifestyle modifications and often experience more severe symptoms and functional limitations.

Physiotherapy for spinal degeneration

Physiotherapy treatment for patients with spinal degeneration is important to assist with pain relief, improve flexibility and strength, and to ensure an optimal outcome. This may comprise:

soft tissue massage
electrotherapy (e.g. ultrasound)
mobilization
traction
dry needling
ice or heat treatment
the use of a back brace or back taping
education
activity modification advice
prescription of walking aids
clinical Pilates
hydrotherapy
exercises to improve flexibility, strength and core stability

Contributing factors to the development of spinal degeneration

age (> 40 years)
a lifestyle that has involved large amounts of lifting, sitting, bending or twisting
history of injury or trauma to the lower back
being overweight
excessive or inappropriate activity
inadequate recovery periods from activity
poor posture
lumbar spine stiffness
poor core stability
muscle weakness or tightness
muscle imbalances
inappropriate lifting technique
biomechanical abnormalities
genetics

Other intervention for spinal degeneration

Despite appropriate physiotherapy management, some patients with spinal degeneration continue to deteriorate. When this occurs, other intervention may be required. This may include pharmaceutical intervention, corticosteroid injection, the use of supplements such as fish oil, glucosamine and chondroitin, investigations such as an X-ray, CT scan, bone scan or MRI, or assessment from a specialist. The treating physiotherapist can advise on appropriate management and can refer to the appropriate medical authority if it is warranted clinically. In more severe cases of spinal degeneration involving spinal canal stenosis or nerve compression, surgery may be required to relieve the pressure on the spinal cord or nerves.

Exercises for spinal degeneration

Initial Exercises

Transversus Abdominus Retraining

Slowly pull your belly button in "away from your belt line" and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 4). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.

Figure 4 – Transversus Abdominus Retraining

Rotation in Lying

Figure 5 – Rotation in Lying