Two important concepts throughout the lumbar fusion therapy protocol are maintenance of a neutral spine and core stabilization. Stabilization can be defined as a balance between strength, flexibility and postural control and a neutral spine can be thought of as a dynamic position between flexion and extension, making it possible to maintain a neutral spine with functional movement and transfers.
Last week a yoga student of mine fell off a ladder and fractured his first lumbar vertebrae. On Monday he underwent a spinal fusion to join together 5 vertebrae, the two above (T11, T12) and the two below (L2, L3). What is a spinal fusion?
With a lumbar fusion, a posterolateral approach is common which means the incision is made from the back. Then a small bone graft (typically taken from the hip or a cadaver) is placed between the transverse process on each side of the vertebrae. The bone grafts assist the vertebra to heal together through the production of new bone tissue into more solid bone mass. After the graft is placed, the vertebrae are immobilized with screws and/or small plates, and often 2 rods are vertically attached to the vertebral pedicles to stabilize the fusion and enhance new bone growth. Often a brace is worn after surgery for up to 3 months when the patient is out of bed.
With a cervical fusion, an interbody fusion is more common, which means the intervertebral disc is removed. There are 4 types of interbody fusions.
The Rotator Cuff:
Infraspinatus- Major external rotator
Teres Minor- Assists with external rotation
Subscapularis- Internal rotator
All 4 muscles serve to stabilize and perform the above actions on the head of the humerus without allowing the scapula to overcome the glenohumeral joint. The result is a smooth rotational movement of the joint to allow for upper extremity elevation in the transverse plane (arm up and shoulder down).
Rotator Cuff Syndrome is an inflammatory or degenerative disorder of the rotator cuff and may also include the biceps tendon and surrounding bursa. It can also include: Supraspinatus Syndrome, Subacromial Impingement Syndrome, Biceps Long Head Tendonitis, Adhesive Capsulitis and RC impingement (frozen shoulder).
For Frozen Shoulder and RC dysfunction:
1. Posterior capsule lengthening (put hand behind back and stand up straight or lie on affected side with arm in front of you), Anterior capsule lengthening (lie in supine with arm sideways above 90 degrees – palm up)
2. Scapula Gliding in all directions: inferior, posterior, lateral and rotational.
3. Scapula retraction (prone, standing, sitting) to assist with positioning the glenohumeral joint.
4. RC strengthening exercises (many in prone which work muscles eccentrically, focus on rotation before elevation)
5. Wall push ups; ball at wall or on table with single arm (closed chain).
All information based on the work of Terry Trundle, PTA, ATC, LAT
Wheelchair Seating & Positioning
Laura Staton, OTR/L, RYT
Staten Island University Hospital
The pelvis links the vertebral column with the LE’s and defines the base of the trunk.
Pelvic bowl formed by 2 pelvic bones (ilium, ischium, pubis) and sacrum.
Important bony landmarks are ASIS, PSIS and ischial tuberosity (sitting bone).
The 2 pelvis bones attach to the sacrum at the sacroiliac joints with strong ligaments. The SI joints so firmly bind the pelvis to the sacrum that each tilt, rotation and postural shift affects the spine.
A posterior tilt flattens/rounds the lower spine, the anterior tilt increases lordosis.
It’s not the just the pelvis that has to be back in the chair, it’s the sitting bones, which insure proper positioning of the pelvic bowl, sacrum & spine.
The spine has 4 curvatures: 2 concave (cervical & lumbar) and two convex (thoracic & sacral).
Cervical & lumbar are lordotic curvatures.
Thoracic & sacral are kyphotic curvatures.
In fetus, the entire spine is kyphotic and curvatures develop as we crawl, sit & walk (specifically the cervical and lumbar curvatures).
All four curvatures act together as a flexible springboard to maintain our upright posture and balance.
When seated, the curvatures are more difficult to maintain (especially with tight hip flexors).
Intervertebral discs are comprised of a gelatinous inner core called the nucleus pulposus (approx 15% of total mass) and confined by the fibrous ring of the annulus fibrosus.
As the spine ages (20-70) the disc dehydrates and vertebral bone loss occurs. The annulus fibrosus takes more weight with compressive forces.
Forward flexion of the spine posteriorly herniates the spine.
Posterolateral herniations are the most common and typically the cause of nerve pain due to the proximity of the nerve root.
Approximately 95% of posterolateral lumbar herniations are at the L4-L5 or L5-S1 vertebral level.
Spinal extension is good for posterolateral herniated discs, flexion is not.
Tonic Labryinthine Reflexes
TLR is an infant reflex which helps baby to master head and neck control, increase tone in trunk and self correct posture & head alignment.
Forward/prone: As head curls in to flexion entire body, UE/LE’s and trunk curl into flexion.
Backwards/extension: As head extends the entire body, UE/LE’s and trunk curl unfold in to extension
Tone can effect w/c positioning
Forward/Prone TLR – pull your knees up towards your chest and notice what happens to your lower back and trunk: Hip Fx, Kyphosis, Parkinson’s, Spinal Stenosis, MS, CVA, SCI.
Backwards/Supine TLR- Sit on edge of chair and extend head and legs out straight and notice what happens to your body: CVA, SCI, Neurological Disorders, TBI.
What Can We Do To Help?
Prioritize w/c positioning as a part of your scope of practice and treatment time.
Do not be afraid to problem solve with patient (client centered care) and make changes.
Ask for help if you can’t figure out what to do.
Educate yourself and the patient.
Change if it does not work.
Questions to Ask Yourself!
Do they LOOK comfortable in chair?
What are patients here for?
Where do they have pain?
What is their static sitting posture/balance?
Are the hip flexors excessively tight?
Are they w/c bound at home?
Do they complain of pain after sitting in chair?
Are they excessively stiff when they get up?
What Improves Wheelchair Positioning?
The right fit of w/c.
Good usage of equipment (SSI, lumbar support, cushions, back support, lateral support, arm tray, calf panels, knee spreader).
The spine and pelvis (as much!) in alignment as possible.
Neutral pelvis with IT bones touching back of seat.
Back support to reduce pain & increase thoracic spinal /neck extension.
Lateral leaning supported.
Feet and limbs supported.
Basic Guidelines to Follow.
With a THR ALWAYS have a SSI.
With a Hip FX, Stenosis, Low Back Pain, Spinal Surgery, kyphosis – SSI may be highly appropriate.
With kyphosis and back/neck pain lumbar support should be considered.
Any skin breakdown or history of skin breakdown use a specialized cushion.
With excessive lateral leaning consider a specialized cushion to prevent skin breakdown on one side.
Consider a knee spreader to assists with organizing alignment.
With a CVA check to see if they need lateral support? Knee spreader?
If very tight hip flexors use extra cushion to elevate pelvis and stretch front of thighs.
Moore and Dalley (2006). Clinically Oriented Anatomy, 5th edition, Lippincott Williams & Wilkins, Baltimore, MD.
Lasater, Judith (2009). Yogabody: Anatomy, Kinesiology, and Asana. Rodmell Press, Berkeley, CA. H. D. Coulter (2001). Anatomy of Hatha Yoga, Published by Body & Breath, Inc. Albany CA.
Last week I taught a chair yoga class at Publishers Clearing House in Chelsea as part of their corporate wellness day. Dues to space (and time) limitations we ended up doing two 30-minute sessions. Although not easy to interrupt deskwork fever to do a mindful yoga practice in the middle of the day, the participants were elegant, thoughtful and positive in attendance and approach. As expected, lots of very tight hamstrings, hip flexors, rounded shoulders and tight pectorals. Computer time breeds a collapsed chest and tight neck and shoulders, so the back/neck/chest stretches were helpful and immediately helped to re-calibrate posture. Additionally, often the fancy ergonomic office chairs are don’t provide enough lumbar support so an addition cushion is helpful. Literally, even a 10-minute yoga breather can break up the physical stress and re-pattern towards better alignment. A cheat sheet of yoga poses were provided.
I decided to bite the bullet the last weeks of August and begin my study of Integrative Yoga Therapy at Kripalu Mass. Integrative Yoga Therapy was started by Joseph and Lillian LePage and is based on a multi limbed approach to yoga therapy integrating asana, pranayama, mudra, Yoga Nidra, mantra, and meditation into a unifying whole – either for therapeutic group classes or private sessions.
As Sergio and I first approached Kripalu, I was regretting that I had recently read “Going Clear” a book about scientology that my friend Lisa Jean had raved about. In fact, moderately panicked about the whole situation and lack of coffee until 7:30am with a 5am wake up time, Sergio kindly drove to the nearest K mart and bought me a 20$ coffee maker and a pound of Peets coffee. I had three roommates; each one was awesome and very charming. A librarian who showed me a photo taken of her aura, a Bulgarian diplomat who also liked coffee, and psychologists who was training in yoga dance.
My colleagues were by large, thoughtful, professional yoga teachers and healers and the teachers committed professionals. We were in class from 6am-9pm almost every day and I have a binder that will take me a year to read. I went to tanglewood and listened to Beethoven’s 9th and cried, went swimming once, went to a “seedy” gay bar (which in Lenox looks likes Chelsea’s finest), took hour long hikes with Lisa and Helen when possible and was constantly trying to corrupt my friend Geetha with daily coffee. Mostly though, I sat and listened and practiced and learned and look forward to my next modules training at an Ashram, in Texas, in March. (Yikes).