Rehabilitation of the Spine: A Practitioner's Manual

REHABILITATION OF THE SPINE A PRACTITIONER'S MANUAL

Editor

CRAIG L1EBENSON, DC Los Angeles, California

-

Q) ~.J Williams & Wilkins A WAVERLY COMPANY

I !

I

II,\[T[MORE' I'H[!.\DEI.I'H[A • 1.0~DO~ • 1',1[\[$ • IIASGKOK HONG KONG. MUNICH· SYDNEY· TOKYO' WROCL\W

1996

°1

,.-...... I \ j I

..

,

')

t...1

:

I

Contents

Seclioll I. Basic Principles

1. Guidelines for Cost-Effective Management of Spinal Pain

,.', \ ..:1 .

.

.. . . . . . . . . }

CRAIG UEBENSON

2. Integrating Rehabilitation into Chiropractic Practice (Blending Active and . 13 Passive Care) . CRAIG UEBENSON

3. Training and Exercise Science

...•.•...... .45

JEAN P. BOUCHER

Sectioll ll. Assessment of Musculoskeletal Function

4. Pain and Disability Questionnaires in Chiropractic Rehabilitation

57

HOWARD VERNON

C) 5.. Outcomes Assessment in the Small Private Practice

t

...................73

CRAIG UEBENSON and JEFF OSLANCE

6: Evaluation of Muscular Imbalance

II

()

,~

(

97

VLADIMIR JANDA

7. Diagnosis of Muscular Dysfunction by Inspection

............... .113

LUDMILA F VASILYEVAand KAREL LEWIT

................ 143

8. Evaluation of Lifting

.•

oJ}

()

LEONARD N. MATHESON

Sec/ion 111. Patient Education

9. Back School

153

PAUL D. HOOPER

()

I

10, Patient Education '

I~

()

.

Appendix IO.l How to Care/or Your B(J(:k "lid Neck: A Sec/ioll Addrc.'i.\"cd J(J the Patient __ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .

J

\ ()

.

1~

CRAIG UEBENSON and JEFF OSLANCE

169

Section IV. Functional ReslOrarioll ll~

Role of Manipulation in Spinal Rehabilitation

195

KARELLEWIT

)l;iii

CONTENTS

12. 'Spinal Therapeutics Based on Responses to Loading

.225

GARY JACOB and ROBIN McKENZIE

13. -Manual Resistance Techniques and Self-Stretches for Illlproving Flexibilityl 253 Mobility CRAIG L1EBENSON

14: Spinal Stabilization Exercise Program

.

. . .21.)3

JERRY HYMAN and CRAIG L1EBENSON

Appendi.\' 14.1 Ex.ercise Checklist

. ..•.....•.•......316

.

15. Sensory Motor Stimulation

319

VLAOIMIR JANDA and MARIE vA vRovA

16. Postural Disorders ofthe Body Axis

329

PIERRE· MARIE GAGEY and RENE GENTAZ

17. Lumbar Spine Injury in the Athlete

341

ROBERT G. WATKINS

18.- Active Rehabilitation Protocols ..................................... 355 CRAIG LIE BEN SON

Sectioll

\~

Psycho.weial and Sociopolitical Aspects of Rehabifiwrioll

19. Psychosocial Factors in Chronic Pain.......

.,

391

GEORGE E. BECKER

20. PatientIDoctor Interaction

A05

WILLIAM H. KIRKALDY·WILLIS

21. Place of Active Care in Disability Prevention ......................... All VERT MOONEY

Index

.

I ~

i- - - - , - - - - - - - - - - - - - - - - - -

.

AI9

I BASIC PRINCIPLES

· t}

1I I

I

.~

1

,j

! -! ~

~

,, ~

l

\-J

I,I

.--~

'J}

(11 >9

iI

()

1 {)

!g )

,>

I (~

1

I

~,

J

{}

0

1 GUIDELINES FOR COST-EFFECTIVE MANAGEMENT OF SPINAL PAIN CRAIG L1EBENSON

MISDIAGNOSIS AND MISMANAGEMENT OF THE PROBLEM Em'crging evidence indica(c~ the problem of low bad: pain has been mismanaged on a gr;md scale. From overprescription of bed rest to overuse of surgical intervention and advanced imaging techniques. the costs related [0 low back pain afC unccilwincd. The U.S. govcrnmcnl reccntly issued federal guidelines on .acme low back pain aimed at promoting a quoJlit)' care modeL I RC Most of these individuals recover within 6 weeks, but 5 to 15% arc unresponsive to treatment and have continued disabili ty 7-'O (Fig. 1.1). The minority of patients who do not recover within 3 months ae· count for up 75 to 90% of the total expenses related to this health care problem,1l-17 which exceed $60 billion per year in the United Slates. 11 The 7.4% of patients who arc out of work for 6 momhs account for 75.6% of the 101'11 cost lll (Fig. 1.2). The majority of these costs (60%) are attributable to indemnity. with only 40% related to treatlllcm ll . 15 (Table 1.1). Among those patients whose symptoms resolve. recurrences arc COllllllon. In some studies. recurrence rates were as low as 22 to 36%.I'}-21 Berquist·Ullman and Larsson found Ihat 620/c; of patiellls with acute back pain suffered at least one recurrence during I year of follow-up. 10 A long·term study revealed that 45% of patients had at least onc significant recurrence within 4 years. 22 The incidence rate. cost of chronicity and disability, and high recurrence ralC add up lO a problem of epidemic proportions. In his Volvo award winning paper. \VaddclJ stated. "Convcmional medical treatment for low-back pain has failed. ~md lhe role of medicine in the present epidemic musl be critic::llly eXtllnined:·~.\ The cause of this epidcmic involvcs a number of f"ctors. The reasons for this fail· ure or treatment .md potcntial solutions .are presenteu in Table 1.2.

Ovcrcmphasis on a Structural [)iclgnosis Artcr ivtixtcr and Barr's, discovery that compn::ssiol1 of a nerve root by a hcrnialc:. 1989. pp 19-33.

- _..----_ _._---._--

.

u i (~

..

'.

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

!

I ! i

18. Sri,,,, wo. Lc Oboe FE. i)urul, M." ,,, S,I,,,,llk "ppn""h IU Ih' ;\s:>cs~mcnt and man3~.:mO:IlI of :lCli\ II~ -rdalc,l spillal disort!crs: A

rtlOllognlph for diniciallS. R~pUI1 lit" llw AT. Hilycr JC. cl 31: Cost.. d fectivene55 of a back school intervention for municipal employees. Spine 17: 1224, 1992. 107. Moffcll JAK, Chase SM, Portek I. et al: A controlled, prospective study to evaluate tlte effectiveness of a back school in the relief of chronic low back pain. Spine 11:120. 1986. 108. Versloot JM. Schilstra N, Tolen FJ. et 31: Back school in industry. A prospective longitudinal controlled study (3 YC3rs). ISSLS Meeting, Miami. FL, April 13-17.1988. 109. Nordin M. Frankel V. Spengler OM: A prc\'enti\'e back care program for industry. Presented at thc International Lumbu Spine Meeting. Paris, May 1981. llO. Rl~rwick OM. Budman S. Fddstein M: No c1inic at risk of becoming disabled because of low-back pain. Spine 16:605, 1991. 117. Waddell G. Newton M, Henderson 1, el al: A fcar-avoidance beliefs qucstionnaire and the role of fear-avoidance beliefs in chronic low back pain and diS3bility. Pain 52: 157.168, 1993. 118. 1c1.1,i A, Adams HE, Swkcs GS, ct "I: An identific '5-" Decreased thickness of collagen libers 'l'I_~ Disk biochemistry Decreases oxygen~' Decreases glucose~l Decreases sullate 2 ' Increases lactate concentralion~.l' Decreases proleoglycan cooteot n

Bone Decreases bone density:n-3' Eburnation" Muscle Decreased thickening of collagen fibers 18 .3.l' Decreased oxidative polential1.... 3~ Decreased muscle mass::'2.3C>-3? Decreased Sarcomeres'o Decreased cross-sectional area t l -4) Decreased mitochondrial contenr" Increased connective tissue librosis"~ Type 1 muscle alroph~2.,o."T Type 2 muscle atroph~e.• ~ 20% loss of muscle strength per weekUl Cardiopulmonary Increased maximal heart rate~' Decreased va: max,"l Decreased plasma volume'"' (From liebensoo C: Pathogenesis of chronic back pain. J Manipulative Physiol Ther 15:303, 1992,)

nonnal after 8 weeks. After 5 months of reconditioning. stiffness was reduced to only 7% of nonnal levels.} Five months of reconditioning improved the tissue failure rate to 80% of normal. and after 12 months of reconditioning, the ratc was completely nonnal.}

FUNCTIONAL DEFICITS ARE PROSPECTIVELY CORRELATED WITH LOW BACK PAIN

Patients typically become inactive when they cxperience pain, and this inactivity promotes dcconditioning. \Vith deconditioning comes greater susceptibility to typical postural or occupational repetitive strains. A chronic cycle of recurring pain is easily established unless function is restorcd./lf pain relief is the only goal of treatment. and functional restoration is ignored, painful recurrences arc more likely". Spons medicine specialist Stanley Herring says, "signs and symptoms of injury abate. but these functional deficits persist. ' . , adaptive patterns develop secondary to the remaining functional dcficits,"~ Focusing on function helps patients to develop control over their symptoms and to prevent recurrences. In many retrospective studies, investigators have documented that various functional changes in musculoskeletal performance arc associated with episodes of bnck pain. al-

though tht:y C:l 11 1l0t dctcrminc if (hcse changcs are a cause or :1 rc:,uh of lhc pain. Prospcclivc studies come closer to id"'lltiryin~ clioll\gic factors. Thc goal of such research is to idctltify what factors are causally linked to low back pain epi:'Olks in a prcdictivl: manner. The following studies arc all pnlspCl:liw, i\('

I

I

,

2

3

4

5

6

7

, )

STRAIN ('X. Elongation) Fig. 2.5. Stress-strain curve lor a ligament. (From Bogduk N, Twomey LT: Clinical Anatomy of the Lumbar Spine. 2nd Ed. Melbourne. Churchill Livingstone. 1991.)

pectcdl)' applied oul'ing their vulncrable. recovcry pk,~~."M According to Andcrsson ... It is generally believed thai r~pe!i­ tive loading causes failure becausc of faligue of the various tissues:· I •.\ Brinckmann and Pope condudc under repetitivc loading. the yield strc~s of thesc l1lillcriilb .tIld the strength of struclllres buill from these matcrials i:-: n:duccd with respect to the stress or strength obscrved under a single load cyclc..f .... (Fig. 2.7). l?educillg ('xjJo.mre 10 high /t.\.e/.\" of load-sllch as trunk flexioll wilh eilher CO/1//u·(!.uiofl or rota-

,

.,

;;

tion-is Ol/e! of 1he 1110.\·1 i/1/{Jorlwll le/1('I.\" (~r pre vclIIioll oj 1011' .~

11

250

STRESS

200 -19\ -------LOAO 150

INI

CONTROL

100 50

oO~-:-l--:2--'30'--'-4--:;;--'6:-' OEFORMATION (mm) Fig. 2.8. The strength of rested tissue deteriorates dramatically compared 10 normal tissue. In this medial collateral ligament of a rabbit knee thai rested for 9 weeks, two thirds of the strength has been lost. (From Mooney V: The subacute patient: To operate or not to operate. In Mayer TG, Mooney V, Gatchel RJ (eds):

Initial length

I

Set

Contemporary Conservative Care for Painful Spinal Disorders. STRAIN

Final length

Baltimore. Williams & Wilkins. 1991.)

Neuroph)'siologic Factors

Fig. 2.6. Stress-strain curve illustrating hysteresis. When unloaded. a structure regains shape at a rate different to thai at which it deformed. Any dillerence between the initial and final shape is the ~set." (From Bogduk N. Twomey LT: Clinical Anatomy of the Lumbar Spine. 2nd Ed. Melbourne, Churchill Livingstone. 1991.)

Injury

As tbc activc component of our locomotor system. muscles arc often called on consciously or by reflex to protect othcr tissues' under stress. Compcns3lOry adaptations (facilitative ;llld inhibitory) typically follow any strain, whether or not it is painful. \Vhat may begin as a segmcntal, reflex muscular 'Idaptalion to pain may become "programmed" in the form of

... ...... -. ... :l

1

recto abd. upper left

Second Record ing

,

""

41

JV

S

", •

~

~ I ". ~

f

~,~ _:~~....L

'....-

6

Fig. 2.21. Electromyographic activity before and alter stretching light muscles. (From Janda V: Muscles. central nervous motor regulation and back problems. In Korr 1M (ed): Neurobiologic Mechanisms in Manipulative Therapy. New York. Plenum. 1978.)

~.

An intermediale muscle type is FR::::':J~I~!_~~y.itch fatigue This typt: resists fatigue but illS0 has f,lst COlli raction nnd relaxation speeds. The FR type has both aerobic and t1naerobic metabolic e:li il,,,::)· ii..::.;d ;" ~'..: propaly traincd. It is csscllli;t1 10 ;H.I. dress deconditioning ;\1lJ leach .. worker 11m\' 10 reduce Ill!.> chunk,1i strcss while :-;.illllllt:lllL:Ollsly training them Hl illlpnm,..• their functional stalU:,>. Individuals wilh "hnnrm,,1 illncss bclwvior arc lIlore likely to becomc dis;lbkd tIl' \0 th:vclop chronic p,lin syndromes. Quick shiftin;; from p:lssivc (nlllscrv;uin:l h) ;lI.:live (rehabilitative) care ,,:an prevent llllH.:l1 disability. Rd~lTal flll" nlllhidisciplin;I1"]' fUlll.·li'lllal n~Sl\lralioll. involving psyclh1logic support and hh)bt'h~l\-ioral rt.'-;.:dueation lllay also he indicated. Although treatlllent dccisions an.: oflcn llIade on the h;'lsis of a di'lgnosis. palicl1\s with spinal pain n:sist ;ILTUf;lle labcling. Painful spimll syndroml:s arc considen:d mcchanical disorders mosl of the lime. bUI many ex pens vicw the psychologic or social factors to bc prcdominant Polin-sensitivc slructures abound in th~ spinal region. :lnd pcrhaps hecausc of the ovcrlap between ~itcs rcferred pain from lllust:les. joints. ligaments. fasl·i;l. nerves. CIt.:.. a diagnosis orten is given on (he basis of lhe physician's pathoph)'siolo~icphilosophy rather than on any provable hYPOlhcsis (i.c.. dcgcncr

.!2~jJ.hY. __<JQ~s. _nm~W_t..9-c.h~on i~ . .~j!L.~~.h!l~.i.!.Hat i(l~l})

Exercises afe performed untBthe point of muscle fatigue only 'so long as proper coordination is maintained. The only pain should be in the muscle being worked (~l ·'burn"). If :.1 symptom.alic area (spinal muscles) is activated during the exercise_ the movement is stopped. When we can achicve an illlcnsity of training that leads to postexercise soreness in dccondiPain-confrontalion Pain-avoidance tioned tissues without exacerbating the original symptoms. we arc well on our way to a successful outcome. Fear of pain Motivation Objectification of function is a key tool in mOli\'ating increased Calibration of patients. Helping patients focus on function rather th,m on Exaggerated pain-stimulus with pain·perceptic pain experienced pain is an important first step. Then. baseline levels of funcSecondary gain Rehabilitalion tional impairment. pain distribution and intensity. and levcl Chronic Full recovery of disability should be qU,

t.,p

b

41

if. Pai;;.II,1 J: ;','Shll": .m.i i,.....IIl.. li,ul. ;:;;,; j'r,'hkllb aud new l·OIIlYPh. In Amhlanl B. IkrlllOl A. C1::lr.ll· F (cd!>,: P.. ~IUfl· anI! ('ail: Ikn'lt'plllent. :\dapt:flinn :U1d ~hxlulalioll. Anbh:nbm. Ehe\'iI;r SCilIrl.' Ilf lrunl. m"lill1\ JmJ IlIllSCIe hllll:li(\n \\illi luw·h;I\:1. ,!I,:::":hty rollin}:... Spill'· I~ :'61. !tJS7. 7't Huhh:ml DR. Bef(,:nifG~1: Myur:L\l:ial tn~;er pnillb :.h~l\l "fk'nl:l11l'UU" needle EMG :'l·ti\"il~. Spill": IR:IKUJ. IlJtl~. SO. Simons DG: Referred phentllncna of 1O~C1fn \tllllu...dc knclh. p:lin anl! mu.~~·lc illlb:\lance. In Harms·Rindahl K (ell): Mu'o.(,;1c Slren~th" New Yurko Churchill Living:;lollc. 1:!.' the
Ins.

5. Roy SH. Dc Luc;1 CJ, C'Isa\,:llll DA: Ltllll!>;lf mu!>dc f:lIiguc :lml

llcxcs and ,....1 \'I:I\'C lollnwill,!C

;1

chiropr;lcllc :ldjuslIllCIlI: A pilot sllldy.

b4

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

III I'ml..'l;cdin!:s of the 1990 Intcrn:ll;on:,t CmlfcrCIICC on Spinal f\h· Ilipublioll. FeER. Arlingl1'{,(J The concurrent validity has been confirmed be(ween the MPQ and the MMPI and many other instrumcnts that measure pain intensity. mood state in pain. and psychosocial disturbance. Phillips and Hunter reported an interesting and significant correlation between MPQ scores and the pain diary in headache subjects.~ With regard to discriminant validity. Dubuisson and Melzack!>-l found that 77% of 95 pain p;.nients could be correctly classil1cd into diagnostic groups on Ihe basis of their MPQ score alone. Reading~7 studied patients with acute ilild

.J

..J

,

.J

, , ; ..

'vM/"\t"j t:H 4 : t"AIN ANU

UI~At:HLlI'Y UW:.::>

IIUNNAIRES IN l,;HIHUI-'HAL; IlL; Ht:.HABILlTATIQN

63

Fig. 4.3. Borg verbal rating pain scale (A) and verbal pain rating scale (6) (from the Roland-Morris scale).

() Patient Directions: On 8 scale of 1 • 10 place 8Jl X In your current pain level NORMAL

( )0

LOW PAIN

MODERATE PAIN

INTENSE PAIN

( )1

( )4

( )7

( )2

()S

( )8

( )3

( )6

( )9

EMERGENCY

( ) 10

A

t:

3

;.,: !! t)

The pain is almost unbearable

I

Very bad pain

,

()

1 j

1

,)

I {)

Quite bad pain

') '.-

Moderate pain

") "
PAIN DIARY

PAIN MAP

Day 3

Htl:::l+t-:::::: - i,; :

Day 4

""

Day 1 Day 2

Day 5

,

,

'-'- -'- -!-'< _L

I

l

[~F::: --

;

-;-

",

,'

"

,Day 18 - - - - - - - -

,+.

'--',

__L.

''l;,,,{

-:

, ?;i

Day 20 -

_

Day 21

,," L Day 22 - - - - - - H+t-+'T-,, H+l-+-f-fLif Day 23

Day 7 Day 8

:::..il Day 24 - - - - - - -

Day 9 Day 10

_

-- -- --.- . Day 19 - - - - - - -

" ' k . . -'

Day 6

Day 16

"H-!-;,;" _.I..! , ' . Day 17 I ! i

. , i-+::::I-H'-H1' ,

Day 25

.-~'\

!

_

+-Ht+-H-+-: .~: Day 26 - - - - - - - L , Da 27 1-· ._L. y -------

Day 11 Day 12

I

I ,

r-r-i Day 28

;j--!-+-+-+,r-=-8

Day 13

_

Day 29

I

Day 14

;-i'~ Day 30

Day 15

Day 31

---------

_

Fig. 4.4. Pain diary.

PAIN BEHAVIOR This section addresses five instruments. the purposes of which .Ire less to describe the p'lin complaint itself than to as-

sess the behavior of the individual in pain Findings from a study of patients with chlonic low back pain by Jensen el al1>7 COtl-

firmed the high dcgn:e of reliability of th(; prolOeo!. They reported inter-rater agreement Kappa c(xflicicl1ts betwecn O.SO and 0.93. Test/retest correlations over I ~ days were al O.7};. \\lilh regard 10 validity. Kecl"c c! al'''' n.:portcd scnsili\'ily 1.0 treatment changes n Ill' r;l1n h.... ha\'il)r in low b:u.:k p:lin palicol\ls durin~ phy:-kal cX:lIuinatiun. 1';1111 ~n:~'it). It)X4.

:-.1. Pil"w:-"~ 1. SI'..·IKC NO: 1';lil1 ;lml 1I1tl':~~ hdl;,,·i,lr: ..\ t.:umpaf;lli\·c slUd\". J 1'.~ydll''''lIIlk~ ~O:IJI. 1lld tin;ll r...."isillllt'l a h'::lhh sl:II11S HlC:I.~uro.:. tkallh Car...• PJ:7R7, [l)S l.

S3. Pollard WE. Bobbill RA. B':I'::nt::T \1. \.'1 :11: Tho.: Skkl\c~s 11lIP:II:t I'wlik: Reliability of a h'::llih sl;\l\1S l1lC;',lIr,', \1..:d ell\: 1-1: 14(1. 1')7(1. R-l, D"'yl\ J{,\: C(ll1lp:lI':lti\"~' \":Ilidity 1'1' th.: Sidll~'SS llllp;ltt Prolik :\I1d shmlcor ~c:lk, fur fllll...·li,lll:11 a...:-...·."m.::1l in It.\\, "a~·k pain. Spin..: II :'J." 1. 19X6. S5. Mill,lrd RW: ..\ crillt:al r~" i.... w Ill' qll·:~tlolln;lir...." f1lr ;I"e... ~ill~ p;lin-I''''lat....d disahility, J Genlp lh·!I:lh 1:~S\J. 1991. S6. Bomb:lnlkr C. TlI~wdl P: 1\klhlltl"I,,~jclll·\,Il~i\kr:lliun' ill rtlll~·li,'nal as~ .... ~!'m..:nl. J RhcullI:lllJ! 1.I(Suppl !:":Il. 11J:'\7.

Outcomes Assessment in the Small Private Practice CRAIG LIE BENSON and JEFF OSLANCE

~

I,

()

I ~

,I

I,

0 Determining. th~ most cosl-clTcCliw IrC.llmclll {kp~nds on appropriate lllcasur~-!.!l~L~).r tr.catlll~lli resulls. Sut.'h measurcment is called ouTcomes lIS.H'SSllll'lIf. The dcvc!()pnlcni·o-r outCOIllC "ssessmcnt tools for -objccti vc measurement of a p lin noninjurod lissue, a sign of neuropathic pain.

]

.J-

·1 I,:~.--------_._---------------

./

t

.;:;

.... n1-\r-1 t.H

:J :

UU I COMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

(.:011111\1 111 _,illJ:llillll ((lmpallil..'s

i" lilt' ;llb.Hross til' ":l1lploycrs ,lIld insur;uKe

;llikl:.

The "~pons medicinc" appro;lt..-h. which l1lcaSUfe~ fulH.:tion;1! impairmcll\ and lI:'\CS active cx..:rdsc to rdl:lbilit:lte in· jured ti'slIcs. is rCl,"ognizcd as the "sl:llldanJ of c;lrc" for :'\ofl tisslIl' injuries.:· t:.;,. This ,Klive approach is bel1er suit..:d 10 ;ll~ Ic\'i;ltill~ p:lill, (ulllpkiing sofl tissll~ he:lling. and pn:\"l:llIing

I

1\.'(ll,"l..·urrI..'IKCS.

i

J.

I (

gi I

01

I

Thc FeE shoultl be m.lI1datory for any patient slill ..:xpericlI(ill); p,lin after 6 to 7 weeks (st:c Chapter 21).1 Thc FCE is (,;ompo~cJ of me;,tsurable functional tests and compk'ments previollsly described questionnain.:.s iscc ClmpICl" -l). The fUlIctional tests mcasure nexibility. strcngth .. ·.mortlinmioll. cntlm'lll(c. ;'lcrobic capacity, posture, and balance. The FeE idclHifies intrinsic jmpairmenls in the individual. Oflell. the extrinsic dClTl.and~ of the work environillent arc thl: o\'l:r\oadin.g or injurious f..tctor. A work capacity e\'alua~ lioll (WeE) or job i.lllulysis Illay be required to identify such potl:llli,11 sources of repclitive overload or injury. The combination of an F"CE, a job "lll,i1ysis. and a WCE will help to idcl1~ lify rctunHo-work outcomes and spccilic crgollomic and excn.'ise instructions for safe sining. lifting. or other repetitive tasks in lhe workpl on more than 500 indiYiduals,7! ."\"sessing impairmcnt i.., crucial to rating t11'..' k\ ~'1 \.'r per\.'1..'111 Ill" illlp;!innclIl ~\ patient !J,IS surfered. II is al.;,' lill: ollly

-

ll:Ihk fr'"11 xon""'}.'-72fi.'>.

Starting position is lhe Same ;,IS for flexion Palienl is requested to side bend maximally to the right/left To minimize rotation. patient is inslructed to slide fingers along the side of their'leg Angle is recorded QI/lIllt ificat iOIl

Ohjf.'l:ti\l·. Quantifiable Tests '

I-'I('X;(lI; / erector

Lateral flexio/l (Fig. 5.3)

Final angles arc recorded Normal vaILlcs~·1 Trunk nexion, 60° v'" Trunk extension. 25°""--Trunk lateral flexion. 25"

v

PIIl/)OSe

Screening tests for erector spin.ac (ncxiotl) or quadratus lumborum (Iateml flexion) tightness Screcning tcst for lumbar joint stiffness

Fig. 5.3. Dorsolumbar lateral flexion.

Ht:HAtjILIIAIIUN Ur I HI:.

TllOradc Spine Range of J\1otioll (Flcx;Ol1IExtcllsitm) (Fig. 5.4) • Patient swnds with knees straight and li..'t:l slightly apan .:...-Scnsors .II1lC as'ncxionfcX1L'IlS1t1!l Patient i~ instructeJ to side-bend nmximally to the IdI and right: angles arc recorded

1 I

Rotatioll (Fig. 5.R)

0'"fn A.M.A. tests. paticnLis_-supilll;;

g~'!Vily_ indin~lIllL'h:r

i~~15!-=.d~

Fig. 5.4. Thoracic lIexionfextension.

• P..l1iCIll TOWles hl.:'ad flllly and angle is rccordl.:'d

t, 'd

~

~--------------------------,~i

~

I

)

"

To itlcntify if ,Isylmnctrk tfUllk rot:Ltioll lllol1ilily is presellt. indicating probable thontcolumbar joint dys~ function een-leal Spine Rauge of /\!o!iou ~V,!.f,.\ F!ex;oIlIExJ('II.\ir", (Fig. 5.6)

I

I

j

Note

1

1

,,.

111;\:\-

if1lally. the new an~k is n:cordcd SCIl:,orS an.:: zeroed :!gain after patient r::lt1rns to upri~h: poswrc femoris) Ir hip flext . . with thigh ahthlt:lioll (TFL I No(('

1

\Vang ct al~~ (est th..: p:,oas hy ~xll.'I1(.Iing thL' hip \\"lJih.. kL'l'pill g the knec cXlcmled. They lllcasurc the 1\':C!U:, fCllloris hy e'xlending the hip with the knl,.'l,.' bent al a 90' angle. For hOlh tests, they pl,lce Ihe inclinollll.'tL'r jll~t supcril1r 10 the p;lldlaL'. Straiglrt l.eg Rai.'(;' (flam.\"i,-iIlJ,: Flexibility J 'Fe..:t (Fig. 5,11 )JJ.J~.~I.~J.;'

;~

1.11"

(psoas)

Patient lies supine on a linn tahle: Sl.'ll:'>llr is pl flexion so that sok faces the ceiling Sensor is placed midtibia (laterally for measuring external rotation and medially for internal rotation) and zeroed Doctor passively internally/externally rotates kg until opposite pelvis starts to move Angle is recorded

Quantification Angle of hip internal/external rotation is measured Nonnal~I,.Ol

38 to 4Y' internal rotation 35 to 45" external rotation

Purpose • To quantify hip internal/external rotation mobilit~ Fig. 5.13. Hip internal rotation.

Note

Fig. 5.12. Quadriceps.

A.I'v1.A. guidelincs test hip rotation whik patient i~ supinc. with kn;::e extell~ion and no pelvic stabilization"l May also be tC"lcd with patient scated~(,",q Supine test with hip and knee at 90" may be used to estimate mobility. Also allows for testing of hip capsule integrity (capwlar dysfunction manifests with pain in internal rotation in this posilion) Gastrocnemius Flexibility Test-1-1,-1~ (Fig. 5.15) Paticnt is supine \vith feet olT edge of tabk Sensor is zc!"o-.::d io vC'l"lical planc and lhl'n placed {)11 sok (11" !"pol

VI IM"- I

en

:J : UU II...oUMt:."

Foot is maximally dorsincxcJ. 11~;lking. :~i.lfC ~;,~ Pl::~ ~::: hcel fully (knl'l' is kcpt in eXlension)

Angle

!,

,

i~ Illea:-illfetl

~'lay a!:-ill hl'

• QUi.lnliry gaslrncl1cmius flexibility

I! I,

I I

Oil

011

Angle or dorsilkxiOIl is n.x:onkd

Normal is 25 to 30"

~ I

pmllc

QfltlUfijinl1 it"l

'I

I

(\1'

Palil..'nl is prone wilh kilt;\,: ht.'1ll hl 90" Sellsor is I.el'nl'u to horizontal pblll.: alld tlll'lI pl:ll"l'd sule of ('oot FooL is lllaxil\l;dly dmsilkxL'd. Ill knee flexion

• Qualifiable tcst for balance, coordinmion. hip extension mobility, and quadriceps strength

Squat Strength/Coordination Test Mt •71 (Fig. 5.19) Patient stands with fcel about shoulder width apan and is instructed to perform a squat

No!e

If heels raise off floor (sokus tightness)

I I

I ,

!'lIr.!'! ":' ()U;tlili;thk l~·~t fllr h:l!:IlIL"\'. ,,','rdin;tlilili.• ;L!.!dn..: ql'" 'Irl·I\~lh. :'(Ik'Il'"

IkxihililY

SEATED .~

.J

l'a"/bil

S !loll!dcr .'\ htlll('riIJII Coordiuotio/l "/('Sl ~ I.'," \ Fi g. :'. ~111 Palil.,.'lll i, "l';l\...-d willi I..-'Ibm\ lh"l'd 1090 11' 1111lil llll-

1\I,ili\\' 11."1 if 'clpubr \.'k\;liil>1l or ftilalilill 11;lll'r:lllyt PIXllr... 111 lir,! .~(l !ll (lO"

W;Lllh.:d f\1\;llillll

P"lil-'lll

i", iU"lnh:h:d In

:-J{l\\"I~ :,hdlH,,:t :trll1

hh:lllify 1\1,,,,

llf

normal glcrll1hullh:r,d rhythm lIl.. . 1Il melhod. Spin.. . 17:42. 1991. II. Lea\·in F. Garron DC. Whiskr WW. et al: ,\ "l,llllparisnn of r:lli~'ll"'. tre;tlcd. by chymopapain and lalllilh:C(Olll)' (ur low l'l:lCk pain usin~ a IIll1l, titlimcllsion:11 pain scale. Clin Onhop 146:136. 1%0. 12. Bt:rnslt:inlH, Jaremko r..'IE. Hinkley BS: On Ih" IJlilily of tht: SCl.-l)O.R Wilh [ow-l'lack pain patiellls. Spine 19:42. 199·l, 13. W'll.klcll G. Newloll M, Henderson I. ct al: A (e;lr-:l"oit!ann: hdi"fs tllll."titlllllairc (FABQ) and the rok of fear-;lvuit!:\IH.:C h\:1il'fs in dlrl11lil· h~·.\'­ back p:lin and disahility. i':lin 52:157. 199J. 14. \Verne!':c ~·1\\'. Harris DE. Lidllcr RL: Clinic.. 1cffecli'·elless (If 0.:11:1\ ii" rial signs for screening chronic low-back pain patients in a work-oriellted physic:II rehabilitation pro£r.lm. Spine 18:2412. 1993, 15, Fairb.lnk JC, DJ,vies JD. Coupcr J, ct at: The Oswcstry low back pain di.o;, ability questionnaire. Physiolherapy 66:271. 19&0. 16. Vernon H. ~tior S.: Neck Disability Indl,':X. j M:tnipul;llin: PhY$iol Th....r 14;..HJ9. 1991. 17. ~. tjllion R. Nilsen K. Ja)'~on MIV. ct al: Evaluation of low back pain and assess men I of lumbar co~elS with and wilhoul back suppol1s. Ann Rheum Dis 40:449. 1981. 18. Vermont Rehabilitation Engineering Centcr: Low Back Paill Questionnaire. Universit), of Vermont. 1988. 19. Roland M. ~·1orris R: A ~tudy of the natural hislol')' of back pain. Spine 8:141.1%3. 20. Lawlis OF. Cuenca... R. Sclb~· D. el al: TIle dC"elopmcnl of Ihe Dalla.' Pain QueMionn3irc for illness bch3\'ior. Spine 14:5 !I. 1989. 21. Deyo RA. Diehl AK: Measuring physical and ,",ychosocial funclion in patientll wilh low-back p:lin. Spine 8:635. 1983. 22. E\·;ms JH. Kagan A II: Dc\·clopmt::nt of functional rating scale to mea· sur.: IrC:ltmcnt OtllComes of chronic spinal paticnb, Spine II :2.77. 1986. 23. Tail RC, Pollard CA. ~brl:olis RH, ct al: Pain disabilitv im!c.'(: Psychometric .tnd validity d:II;. Arch Phys 1I.·1cd Rehabil 12:56i, 1987. 24. Bigo.~ $ .. Banie. Spenglerc OM, et al: A prospective study of work pl,':r"t:ptimls and psychosocial factors :Iffecting the report of b:lck injury. Spine 16:1, 199L 25. \'011 Korff M. Oe)'o RA. Chcrkin D, et ;tl: Back pain in primar)' care: Ou((.'ollles at I year. Spine 18:855. 1993. ~6. D\\\'rkin SF. Von Korff. Whittlcy we..... t al: Meard E,:. Chll·a:;ll. American ~kdic;tl Assodo:llfm, 1l)~K 55. N.Ulscl D. Jans..:n R. CrCfIlo:la E. 1.'1 :II; Elk~·ts of l..'erviL·,,1 :IJ.llhlll\l·llb un lateral-flexion pa...si\"c cnd.r~lllge asyrlllllt:tr)' and un hllll,ld l'r..'~~llfl·. h....arl rate and plasma cateehol
."~."

-,-~,

REHA81l1TATION OF

~o

,-= SPINE: A PRACTITIONER'S MANUAL

IJn'll l'O.\-/tT/t.,. ,;,. ~ lI1use/ex "::1Il h~ lested only hy thor-

U,'/)('/" rra{)(,':.ills (Fig. (\.1) i... h:"ll..'d with thl:

P;l\lt'lll

"-upille.

the head p:lssivcly tk\yd ;.tOt! illl'lillcd 10 Ihcl."lllllralatcl':t1

sid~: Fr-oin Ihi";Z-j;-u:..ilit;n. II~c- ... iullll-d~i-ill~(Ik· i;-ri~;hl..~T.~~;lall y. N(fnh~l1y. a soft b:uTil."r i... at tilL' I..'nd or tile pnsh: \\hl'll the 1ll0VCIl1('ut i:- rcstricll'd. il is hard. L(·\wo,.S("OIJll!ac lFi:::. (l,:!1 i......· ,aulillt:d in:1 silllil:lr man· lll'r. only (hL~ had is ill ;lddili\~J,~,r{.1,1_;11.\':~!I,~lq.1_l,'~.~,!n~r:ll;l!c{alside. Peclomli.\' 11/0)0" I Fi~. (1.:\) i... \J..'stt.:d with thl' patient supine. the ;lrIll I1U~\ctl p;'l:-.si\'dy inlo abdm:liull. The tnlltk must be s(;Jbili".cd hcf(ITI..' the :mll i... pl'lced into ;lhdllL'tion hc· cause a possihle (\Vbl of lilt.: trunk might mimic 11k' normal range of 1ll0VCllH:nl. Thc arm should reach the Iwril.Ontill level. To estimate Ill!,; d,l\icul"r jJllrtion. the ilnll is alll1\\Td to hang down loosely :1I1J the ex'lminer pushes Ihe :-.houh.kr downward. 1 ormally. {lIlly;'1 slight soft barrier is felt.

P'\!p;ltioll. L\ .:i~:,!ii\lll or till' .\IO'lIo('/CitlOIl/c1S/oiti is 1I0l rdi;lhk hCi:;WSl' it ~'r\'''l'S loom;lllY ~l'.:;rnellts {I;·ig. (lAl. lIil'110pl"." lilt".:, .. ,:.... lhg. 6.:'1. n'!'wsll'llloris (Fig, ()J)) ;lrl' !L·~lt.·d with thl' ",:::..'l1t in:\ llHldilil.'d Thomas position. Till.'

\l\1:;h

prl"l"IlI,:d llIodilic:lh':1 ,11"'0 allows l'\,llnin:ltioll or till: ....hon f'"::); addrw/ors ,lIh: ::::.' [I'llsor fiISf';" !:if{/(" Till' p:lIil'llt i... 'll;~:tll' with thc tm~(l on the plinth ,1I1d till.' ll'"ll'd k~ h)\\sl'l~ h_::,~ill~. The 110111l>,te(l leg is 1ll:lxilllally Ikxl,.'d to sl"hilit:I,.' Ill;: ;'l.'h·is and tlall~n Ih~ IlImb;II' spine. TIl(' Ikxion pllsitioll in (h~' hip joint indicatt:~ the tightness or thl.' iliop,oa", th~ nhliqu;.: position of th~ lower kg indicates Ihe tigh\lh:~S of the IS:'lU'. ThL: inability' 10 ;lchicvc passively thl.' hYPL:I\~.\tcll.'iioll ill Ill:.: hip joint .111\.1 thl.' in

, ....i

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

105 Fig. 6.15.

Hip extension.

Fig. 6.17.

Hip abduction.

Fig. 6.18.

Trunk curl up.

Fig. 6.19.

Push up.

,vv

lion of the scapula, and elevation of the shoulder girJk. Tlte ; decisive movement is identifying im:oordil1;11ion is lhe devalion (hm normally starts to occur at ..thou! 6()" l}f . lbdtKliml. 'Ill

6 I .111 individual with shoulcJcr dysfunction. e1c\'aliOl~ 51.u'ts C~lr­ \.Jic:r or may even inilialc the movemenl. ANALYSIS OF MUSCULAR IMIIALANCE IN STANDING

In "Ul an.dysis or sl:.Illuing. all ;ltlcmj1t is maue to diffcrcn~ tialc bc(,,,,'cclI possihk provOL: