Back Me Up! Dr Judi Laprade Associate Professor, Division of - - PowerPoint PPT Presentation

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

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Essential’s of Clinical Anatomy; Moore,13e

Segmental Movement

• Movements freest in C region: facets

large and almost horizontal

• T region: stability due to connection of

ribs and costal cartilages to sternum; Rotation good; Flexion and lateral flexion limited (2-3 degrees/segment).

• L 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

• Muscles either originate or

insert to the spine

• 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

• Muscles originate off of

spinal segments & ilium

• Insert onto ribs, spinous or

transverse processes

• Prime movers of the spine
• ERECTOR SPINAE group

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Principles of Human Anatomy, Torotora 14e

Deep Spinal Muscles

• Muscles ALL originate on the

transverse processes

• Insert onto the spinous processes

above (1-6 segments)

• Act to either rotate (unilateral) or

extend (bilateral) spine

• 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:

• Gravity/weightbearing forces
• 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
• verall 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

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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

• steoporosis?

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
• nly 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:

• Fixed? Flexible?
• Scapular girdle protraction alone?
• Combined scapular & thoracic?
• Likely to be exacerbated by

work/ADLs?

• A muscular strength or endurance

issue?

• What is the most likely successful

exercise prescription they will DO?

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General Guidelines

Postural Change Target

• Scapular protraction
• Supf. Muscles
• Thoracic hyperkyphosis

Erector Spinae

• Scapular & T spine changes

Supf & Erector group

• 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

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• www.osteoporosis.ca
• www.bonefit.ca
• https://www.iofbonehealth.org/
• https://www.facebook.com/toofit.tofracture/