Chapter 16: The Spine: Exercise and Manipulation Interventions (Kisner and Colby)

Goal of mobility/flexibility

increase ROM of specific structures that affect alignment and mobility in the neck or trunk

Interventions should include:

kinesthetic training basic spinal stabilization training functional training

CPGs for neck pain and for low back pain identify strong evidence for

manipulation and thrust techniques to reduce pain and disability with mobility impairments; strong evidence for trunk coordination, strengthening, and endurance and fitness activities when treating patients with back and neck pain

the neutral spine position is

midrange

Kinesthetic training

- Awareness and control of safe spinal motion; head nodding and pelvic tilts - Awareness of neutral spinal position while supine, prone, sitting and standing - Awareness of effects of activities of daily living and extremity motion of the spine

Stabilization training

-deep segmental muscle activation ( controlled axial extension with craniocervical flexion and lower cervical/upper thoracic extension) and lumbar region (drawing-in maneuver and multifidus muscle action techniques) -superficial multi-segmental (global) muscle control of spine posture with extremity loading -passive support of spinal posture only if needed; progress to active control -coordinate segmental muscle activation with maintenance of a stable spine in neutral spine position (or position of bias) with all arm and leg motions

In general stretching is contraindicated in the region of inflamed tissues. Exceptions:

-fluid stasis that restricts movement may respond to repetitive motion or sustained positioning into restricted range -Acute nerve root impingement may be relieved with traction or flexion to widen the invertebrate foramina

Functional training (Basic Body Mechanics with Stable Spine)

-log roll supine to prone, prone to supine -transition from supine to side-lying to sitting and return -transition from sit to stand and return -walking

Guidelines for stabilization training

1. Kinesthetic training for awareness of safe motion and positions must precede stabilization training 2.Activation of the deep segmental muscles of the trunk, specifically the transverse abdominis (TrA) and multifidus (MF) 3. Extremeity motions are added to the stabilization program to coordinate segmental muscle activity with the global stabilizing musculature. Loading via the extremities increases the stabilizing challenge to musculature 4.Increase muscular endurance and strength once control of the spinal position is established and the patient can activate the stabilizing muscles 5.Alternating isometric contractions between antagonists and rhythmic stabilization of the trunk muscles against manual resistance also enhancing stabilizing contractions 6. Transitional stabilization develops as the patient moves from one position to another in conjunction with extremity motions 7. Perturbation (balance) training, exercising against destabilizing forces or unstable surfaces, develops neuromuscular responses to improve balance

After having the patient find the neutral or functional position (bias) then

move the arms and legs to feel the effect on the spine. Control of the spinal position is emphasized, have the patient to practice arm and leg motions and attempt to maintain control

When should aerobic conditioning exercises be initiated?

as soon as the patient tolerates repetitive activity without exacerbating symptoms

fundamental interventions

exercises or skills that all patients with spinal impairments should learn at the time of examination and initial intervention

Kinesthetic awareness

one of the fundamental interventions for spinal rehabilitation is for the patient to develop awareness of safe spinal positions and spinal movement as well as what effect the supine, prone, side-lying, sitting and standing positions have on the spine awareness of what postures make the symptoms better or worse and identifying the neutral spine position of bias are important in helping patients manage their symptoms

if the patient cannot maintain control or the symptoms he or she requires

passive support or passive positioning

_________________key component of every goal and intervention

patient education

the position of symptom relief is called the

position of bias or resting position

Lumbar spine functional training

pt position: begin supine or hook-lying, then sitting, standing, and quadruped teach patient to move his or her pelvis into an anterior and posterior pelvic tilt once patient has moved the pelvis and spine through a safe ROM, instruct patient to find greatest symptom relief if active movement and control are not possible, teach passive positioning

Cervical spine functional training

pt position: begin supine; progress to sitting and other functional postures as tolerated if pt experiencing a lot of pain and not able to move their head or doesn't want to begin with passive movements describe mechanics of what I'm doing have pt to identify the change in symptoms as movement occurs have pt to practice moving into and out of that position to develop control if the pt cannot maintain this position while sitting and standing, wearing a cervical collar may be appropriate during the acute stage following an injury or postsurgically

When the patient is able, stabilization exercises, muscle endurance, and strengthening exercises are integrated with

skills for body mechanics , safe work habits, and effective recreational or sport activities to meet the goals of the individual

In general, movement of the extremities away from the trunk (shoulder flexion, abduction, hip extension and abduction) causes

spinal extension

In general, movement of the extremities toward he trunk (shoulder extension and adduction, hip flexion and adduction) causes

spinal flexion

muscle performance involves

strength, power, endurance, and stability

Mobility/Flexibility

stretching and flexibility exercises as well as mobilization/manipulation techniques are used to increase mobility of restricting tissues so the patient can assume an effective position of the spine when exercising

Goal of Kinesthetic Awareness

to develop proprioception of spinal positioning, safe movement, and postural control