Back Me Up!€¦ · – mobility, dynamic balance, muscle strength, postural alignment 2) safe...
Transcript of Back Me Up!€¦ · – mobility, dynamic balance, muscle strength, postural alignment 2) safe...
Back Me Up!
Dr Judi Laprade
Associate Professor, Division of Anatomy,
University of Toronto
Lead Trainer, Bone Fit
Outline of Presentation
Overview of vertebral anatomy
Overview of spinal musculature
Biomechanics of spinal fractures
Using anatomy & biomechanics to
guide rehabilitation
Sample exercises
Q & A
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Thoracic Vertebral Anatomy
(c) Superior view
ANTERIOR
Spinous process
Lamina
Vertebral foramen
Transverse process
Pedicle
Vertebral body
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Principles of Human Anatomy, Torotora 14e
POSTERIOR
Thoracic Vertebral Anatomy
(d) Right lateral view
ANTERIOR POSTERIOR
Transverse process
Superior
articular facet
Inferior articular facet Spinous process
Vertebral body Pedicle
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Principles of Human Anatomy, Torotora 14e
Role of the
Vertebral Components 1
Essential’s of Clinical Anatomy; Moore,13e
Segmental Movement
oMovements freest in C region: facets
large and almost horizontal
oT region: stability due to connection of
ribs and costal cartilages to sternum;
Rotation good; Flexion and lateral
flexion limited (2-3 degrees/segment).
oL region: flexion/extension good:
sagittally oriented facets; lateral flexion
good; interlocking of facets limits
rotation (2-3 degrees/segment).
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Essential’s of Clinical Anatomy; Moore,13e
Ligaments of Spine
___ Resists Flexion
___ Resists Extension
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Essential’s of Clinical Anatomy; Moore,13e
Superficial Spinal Musculature:
? ‘Postural’ Muscles
TRAPEZIUS
LATISSIMUS
DORSI
RHOMBOID MINOR
RHOMBOID MAJOR
SERRATUS
ANTERIOR
o Muscles either originate or
insert to the spine
o Prime movers of the
scapula and humerus…
NOT direct movers of the
spine
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Principles of Human Anatomy, Torotora 14e
Intermediate
Spinal Muscles
(b) Posterior view
ILIOCOSTALIS
SPINALIS
LONGISSIMUS
o Muscles originate off of
spinal segments & ilium
o Insert onto ribs, spinous or
transverse processes
o Prime movers of the spine
o ERECTOR SPINAE group
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Principles of Human Anatomy, Torotora 14e
Deep Spinal
Muscles
o Muscles ALL originate on the
transverse processes
o Insert onto the spinous processes
above (1-6 segments)
o Act to either rotate (unilateral) or
extend (bilateral) spine
o TRANSVERSOSPINALIS group
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Muscles in
Cross-section
Superficial
Intermediate
Deep
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Essential’s of Clinical
Anatomy; Moore,13e
Physiological Fact:
Sarcopenia & OP Co-exist
Ciolac, 2013
http://www.scielo.br/scielo.php?pid=S1807-59322013000500710&script=sci_arttext
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Osteoporotic Fractures
ABNORMAL FORCE NORMAL FORCE
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Habitual slouching posture, repetitive lifting, or ADLs which encourage flexion of spine
Move the line of gravity anterior to vertebral
body increasing flexion moment
Resulting
MICROFRACTURES of
anterior vertebral bodies
Increases spinal extensor muscle activity to
counter the flexion moment
10-fold increase in
compressive forces on
anterior portion of
vertebral bodies in
thoracic region compared
to erect posture
Extensor muscle contraction further
increases vertebral compression loads &
accounts for 92-100% of stress on spine
PRESENCE of suboptimal bone density
ANTERIOR WEDGING & FRACTURE
DEVELOPMENT OF POSTURAL HyperKYPHOSIS
(Briggs, 2004; Sinaki, 2007; Duan, 2001)
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Anatomy Application to OP
Bone responds to two main forces:
o Gravity/weightbearing forces
o Muscle resistance/pull
Asymmetrical weightbearing forces on thoracic vertebral
bodies often lead to wedging fractures & cascade
No muscles attach to the body of thoracic vertebrae….
It shouldn’t be surprising that:
Anatomy + Mechanics biases thoracic vertebral bodies
for fractures!
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• Height loss
• Upright posture becomes impossible (increased kyphosis)
• One thoracic vertebral fracture = 9% loss of forced vital capacity (breathing difficulties)
• Protruding abdomen Distension, constipation, digestive issues, loss of appetite
• Increased risk of death
• Vertebral fracture increases the risk of hip fracture 2-3x; and overall risk of having another vertebral fracture is 4x
Consequences of
Vertebral Fractures
It is the most common fracture that occurs as a result of osteoporosis. Ioannidis et al 2009
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• More muscle co-contraction, leading to more vertebral loading more fractures
• Increased chance of more vertebral fracture and more kyphosis
• Increased sway…or poorer balance reactions more falls
Consequences of Increased
KYPHOSIS
Katzman, et al., 2010;
de Groot et al., 2014
Greig, et al., 2014
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Supine lying
Implications 3
Implications:
Movement Guidelines
• SPINE MOVEMENTS should minimize:
REPEATED/SUSTAINED, WEIGHTED,
END-RANGE, RAPID/FORCEFUL or COMBINED:
• Flexion/Rotation/Side Bending
– Reduce the cumulative effect of flexion/slouching/rotations (ADLs & Work ergonomics)
– Improved awareness/ergonomics for lifting/lowering heavy loads
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What therapeutic goals should
be targeted for individuals with
osteoporosis?
PREVENT FRACTURES via:
1) fall prevention:
– mobility, dynamic balance, muscle strength, postural
alignment
2) safe movement:
– postural alignment and body mechanics to protect the
spine
– muscular endurance in spinal extensors
– stretch muscles restricting mobility or optimal alignment
3) prevention of further bone loss:
– exercise may not have a guaranteed effect on bone
mineral density
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Giangregorio LM, et al. Osteoporos
Int 2014; 25: 821-835
Exercise Frequency Examples/Comments
Strength Training ≥ 2x/week
• Exercises for legs, arms, chest, shoulders, back
• Use body weight against gravity, bands, weights*
• 8-12 repetitions maximum per exercise
Balance Training ~ 20mins daily
• Standing still: one-leg stand, semi-tandem stance, shift weight
between heels and toes while standing
• Dynamic movements: Tai Chi, tandem walking, dancing
• Progress from standing still to dynamic
Aerobic physical
activity
≥ 5x/week
(30min/day)
• Do bouts of 10 min or more
• Accumulate ≥ 30 min per day
• Moderate- or vigorous-intensity (5-8 on 0-10 Borg scale)*
Posture/ Back
Extensor Training
5-10mins
daily
• Lie face up on firm surface, knees bent, feet flat. Use pillow
only if head doesn’t reach floor. Do this 5-10 min/day.
• Progressions 1) lying with gentle head press, without changing
chin position, perform 3-5 seconds “holds”; 2) Erector spinae
activation in standing
Spine Sparing
Strategies
During daily
activities
• Learn a “hip hinge” and “step to turn” so that you can modify
activities that flex (bending forward) or twist spine
Exercise and Activity
Recommendations
*In presence of vertebral fracture, emphasize good alignment, and moderate over vigorous intensity aerobic
activity and consult Bone Fit trained Physical Therapist
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What’s so important about
daily spine sparing?
10-fold increase in
compressive forces on
anterior portion of
vertebral bodies
ANTERIOR WEDGING & FRACTURE
DEVELOPMENT OF POSTURAL HyperKYPHOSIS
Habitual slouching posture, repetitive lifting, or ADLs
which encourage flexion of spine
More loading on
vertebral bodies
More postural
sway & falls
MORE FRACTURES &
Morbidity/mortality
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Teach “spine sparing” during ADL
and physical activity…. How?
• Utilize a hip hinge and/or Modified
Golfer’s Reach for many ADLs and
work needing spinal flexion
• Limit lifting from or lowering to the floor
• Support trunk when flexing
• Hold weight close to body, not overhead
• Minimize sustained sitting or slouched
postures
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Using a
Modified
Golfer’s
Reach
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Using Anatomy &
Mechanics to Rehabilitate
1. Remember & apply your
anatomy knowledge
2. Address the known tight/weak
muscle groups
3. Think about load & transitions
4. Treat to target
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Treat to Target
Client with OP & ‘poor posture’
Is the poor posture:
o Fixed? Flexible?
o Scapular girdle protraction alone?
o Combined scapular & thoracic?
o Likely to be exacerbated by
work/ADLs?
o A muscular strength or endurance
issue?
o What is the most likely successful
exercise prescription they will DO?
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General Guidelines
Postural Change Target o Scapular protraction Supf. Muscles
o Thoracic hyperkyphosis Erector Spinae
o Scapular & T spine changes Supf & Erector group
o Shoulder Impingement/
‘Frozen Shoulder’ Look at T Spine
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Back Extensor Training
Daily for 5-10 min
• Perform 3-5 exercises and repeat 5-8 times; hold
each repetition for 3 seconds
• Can perform different exercises or the same
exercise in different positions (preferably lying flat
standing sitting)
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Back Extensor Training
Examples: 2 in 1
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In your practice, consider:
• Do you assume fractures and postural and height
changes are ‘normal’?
• Do you incorporate safe movements* into your
treatment and exercise programs?
• Do you give preventative ‘homework’ for your
client’s ADLs?*
(*refer back to slide on movement guidelines)
How will you individualize treatment to reduce falls
and fractures?
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FINAL THOUGHTS
Encourage attention to posture, exercises for back extensor muscles daily
Instruct on spine sparing strategies for ADLs, fun & work to ↓ spine loads
Teach clients how to move instead of how not to move
Q & A 6
o www.osteoporosis.ca
o www.bonefit.ca
o https://www.iofbonehealth.org/
o https://www.facebook.com/toofit.tofracture/