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 1 Overview of spinal musculature 2 Biomechanics of spinal fractures 3 Using anatomy & biomechanics to 4 guide rehabilitation Sample exercises 5 Q & A 6

Thoracic Vertebral Anatomy 1 Spinous process Vertebral foramen Lamina Transverse process POSTERIOR Pedicle ANTERIOR Vertebral body Principles of Human Anatomy, Torotora 14e (c) Superior view

Thoracic Vertebral Anatomy 1 POSTERIOR ANTERIOR Superior articular facet Vertebral body Pedicle Transverse process Inferior articular facet Spinous process (d) Right lateral view Principles of Human Anatomy, Torotora 14e

Role of the 1 Vertebral Components Essential’s of Clinical Anatomy; Moore,13e

Segmental Movement 1 o Movements freest in C region: facets large and almost horizontal o T region: stability due to connection of ribs and costal cartilages to sternum; Rotation good; Flexion and lateral flexion limited (2-3 degrees/segment). o L region: flexion/extension good: sagittally oriented facets; lateral flexion good; interlocking of facets limits rotation (2-3 degrees/segment). Essential’s of Clinical Anatomy; Moore,13e

Ligaments of Spine 1 Essential’s of Clinical Anatomy; Moore,13e ___ Resists Flexion ___ Resists Extension

Superficial Spinal Musculature: 2 ? ‘Postural’ Muscles RHOMBOID MINOR o Muscles either originate or RHOMBOID MAJOR insert to the spine o Prime movers of the TRAPEZIUS scapula and humerus … NOT direct movers of the SERRATUS ANTERIOR spine LATISSIMUS DORSI Principles of Human Anatomy, Torotora 14e

Intermediate 2 Spinal Muscles o Muscles originate off of SPINALIS spinal segments & ilium LONGISSIMUS o Insert onto ribs, spinous or transverse processes ILIOCOSTALIS o Prime movers of the spine o ERECTOR SPINAE group (b) Posterior view Principles of Human Anatomy, Torotora 14e

Deep Spinal 2 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

Muscles in 2 Cross-section Deep Intermediate Superficial Essential’s of Clinical Anatomy; Moore,13e

Physiological Fact: 2 Sarcopenia & OP Co-exist Ciolac, 2013 http://www.scielo.br/scielo.php?pid=S1807-59322013000500710&script=sci_arttext

Osteoporotic Fractures 3 ABNORMAL FORCE NORMAL FORCE

Habitual slouching posture, repetitive lifting, or ADLs which encourage flexion of spine 3 10-fold increase in Move the line of gravity anterior to vertebral body  increasing flexion moment compressive forces on anterior portion of vertebral bodies in thoracic region compared Increases spinal extensor muscle activity to to erect posture counter the flexion moment Resulting Extensor muscle contraction further MICROFRACTURES of increases vertebral compression loads & anterior vertebral bodies 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)

Anatomy Application to OP 3 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!

Consequences of 3 Vertebral Fractures • 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 It is the most common fracture that occurs as a result of osteoporosis. Ioannidis et al 2009

Consequences of Increased 3 KYPHOSIS • More muscle co-contraction, leading to more vertebral loading  more fractures Greig, et al., 2014 • Increased chance of more vertebral fracture and more kyphosis Katzman, et al., 2010; • Increased sway…or poorer balance reactions  more falls de Groot et al., 2014

Implications 3 Supine lying

Implications: 4 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

What therapeutic goals should 4 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

Exercise and Activity 4 Recommendations Frequency Exercise Examples/Comments • Exercises for legs, arms, chest, shoulders, back ≥ 2x/week • Use body weight against gravity, bands, weights* Strength Training • 8-12 repetitions maximum per exercise • Standing still: one-leg stand, semi-tandem stance, shift weight between heels and toes while standing Balance Training ~ 20mins daily • Dynamic movements: Tai Chi, tandem walking, dancing • Progress from standing still to dynamic • Do bouts of 10 min or more ≥ 5x/week Aerobic physical • Accumulate ≥ 30 min per day (30min/day) activity • Moderate- or vigorous-intensity (5-8 on 0-10 Borg scale)* • 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. Posture/ Back 5-10mins • Progressions 1) lying with gentle head press, without changing Extensor Training daily chin position, perform 3- 5 seconds “holds”; 2) Erector spinae activation in standing Spine Sparing • Learn a “hip hinge” and “step to turn” so that you can modify During daily Strategies activities activities that flex (bending forward) or twist spine *In presence of vertebral fracture, emphasize good alignment, and moderate over vigorous intensity aerobic activity and consult Bone Fit trained Physical Therapist Giangregorio LM, et al. Osteoporos Int 2014; 25: 821-835

What’s so important about 4 daily spine sparing? Habitual slouching posture, repetitive lifting, or ADLs which encourage flexion of spine 10-fold increase in compressive forces on anterior portion of vertebral bodies ANTERIOR WEDGING & FRACTURE DEVELOPMENT OF POSTURAL HyperKYPHOSIS More postural More loading on sway & falls vertebral bodies MORE FRACTURES & Morbidity/mortality

Teach “spine sparing” during ADL 5 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

5 Using a Modified Golfer’s Reach

Using Anatomy & 5 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

Treat to Target 5 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?

General Guidelines 5 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

5 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)

Back Extensor Training 5 Examples: 2 in 1

In your practice, consider: 5 • 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?

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/