Hospital Care

25
Feb

Thank YOU

In my hospital job, it is customary for my manager Nora to print out letters of appreciation that we occasionally receive from our patients. In honor of that tradition, and as yoga teachers we know it is even less frequent, I am posting a recent email I received from a student. To all the yoga teachers and health care providers, take it in.

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22
Jan

Yoga After a Spinal Fusion – Class 1

Pranayama- Ujjayi breathing in to lower abdomen and diaphragm (lying on back)

Mudra: Rupa Mudra for Bone Health

Body Awareness- place thin support under lumbar spine for isometric abdominal toning (belly button towards spine); one at a time, lift each knee to chest on exhale.

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3
Jan

Spinal Fusion Rehabilitation

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.

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13
Nov

Spinal Fusions

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.

http://www.webmd.com/pain-management/video/spinal-fusion
http://orthoinfo.aaos.org/topic.cfm?topic=a00348
http://www.mayoclinic.com/health/spinal-fusion/my01235

16
Oct

Seating and Wheelchair Positioning

Wheelchair Seating & Positioning
Laura Staton, OTR/L, RYT
Staten Island University Hospital
10/19/13

The Pelvis
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
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).

Disc’s
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

Lab
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.

References:
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.

17
Jul

What are Cervical Stenosis and Myelopathy?

Cervical Stenosis: Is when the spinal canal is too small for the spinal cord. A normal canal diameter is approximately 13-15mm and a narrowing of the canal of less than 10mm diameter is associated with cervical stenosis. A canal of below 13mm is considered at risk for stenosis. Symptoms of cervical stenosis include neck pain and numbness, pain in one or both arms, and an electrical sensation that radiates downwards when the head moves. Radiculopathy are pinched nerves as they exit the spinal canal.

Management of spinal stenosis is aimed toward symptom relief and prevention of neurologic complications. Physical therapy with traction and strengthening exercises help relieve symptoms, muscular spasms and back pain. Decompression and inversion tables have also been used with success and varying amounts of benefit. Epidural steroids are also used to treat stenosis. Surgical interventions may be required in some cases.

Cervical stenosis can progress to myelopathy in one third of affected individuals. Myelopathy is defined as pathology of the spinal cord and spondylosis refers to the degenerative changes that occur in the spine.

Cervical Spondylosis Myelopathy (CSM) refers to the clinical presentation from these degenerative processes and is a common degenerative condition of the cervical spine. Degenerative changes of the cervical spine include degeneration of the joints, intervertebral discs, ligaments and connective tissue of the cervical vertebrae and symptoms can include neck and shoulder pain, suboccipital pain and headache, radicular (radiating nerve pain) symptoms. CSM is the most common cause of spinal cord dysfunction in adults older than 55 years has been observed in as many as 95% of asymptomatic individuals older than 65 years.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899662/
http://emedicine.medscape.com/article/1144952-overview
http://www.aafp.org/afp/2000/0901/p1064.html

13
Jun

Herniated Discs, Sciatica & Spinal Stenosis

Dr Loren Fishman, a back-pain and rehabilitative medicine specialist who has long incorporated yoga into patient care and studies Iyengar Yoga, published an article in the New York Times on 5/8/13 called Advice on Practicing Yoga in Middle age.

Responding to questions about practicing yoga with herniated disc Dr. Fishman made the following statements:

– A herniated disc responds to extension, and may be worsened by flexion

– DGR, with bulging discs, is inhibited from back bends by a yoga-phobic physician. But back bends will very likely help.

– And about 5 percent of the time, the treatments reverse: extension helps stenosis, flexion is good for herniated discs.

– Unfortunately, Cate in NY, who also has sciatica and a herniated disk, cannot do either forward or backward bends. But she can do sideways poses like vasisthasana (side plank), which we have shown with M.R.I.s to reduce stenosis and herniated discs.

So I looked in my anatomy books to understand this more specifically:

Intervertebral Discs and Vertebrae: IV discs join the vertebra together. The fluid, gelatinous inner part of the disc is the nucleus pulposus, and is confined by a fibrous ring called the anulus fibrosus. The discs account for 20-25% of the length of the spinal column and at birth the central core of the disc is 88% water. In middle and older age there is a decrease in vertebral bone density, which causes the superior and inferior surface (top and bottom) of the vertebrae to become increasingly concave. Due to this concavity, the IV disc bodies actually increase in size; women 10% and men 2% (front to back) and in thickness about 10% in both genders. Interestingly, this bone loss and thinning of the vertebral mass are believed to account for the majority of age related height loss. The IV discs become circumferentially broader when the spine is compressed and thinner when stretched (as in hanging or suspended).

Herniation: As we age (20-70), the disc dehydrates and the inner and outer part merge together, forcing the outer ring to take more weight with compressive forces. Flexion of the vertebral column creates pressure anteriorly and over stretches the posterior spine squeezing the nucleus pulposus backwards (posterolateral) towards the thin and overstretched anulus fibrosus. Herniation occurs when the nucleus pulposus pushes in to the anulus fibrosus, which in turn pushes on the nerve roots. 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.

Sciatica: Is often caused by a herniated L4 disc which compresses the L5 or S1 sciatic nerve root. Chronic sciatica causes pain, which can shoot down the posterior leg, and acute sciatica can be the result of localized nerve inflammation. Other causes include a tight piriformis muscle and spinal stenosis. Hip flexion with knee extension can exacerbate or relieve sciatica. Stretching the piriformis/rotator muscles can relieve sciatic as well.

Spinal Stenosis: The canal (foramina) of the spinal cord can narrow with age and compress the nerve roots as they leave the spine. Lumbar Stenosis is most common in the L4 vertebrae. If there is herniation of L4 along with stenosis it further compromises the already limited vertebral canal.

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.
Sciatica.org

16
Mar

Sciatica!

The sciatic nerve innervates all muscles of the posterior thigh, leg and foot. It is as thick as a finger and is formed from the nerve roots that originate from the sacral plexus (groups of nerves) that emerge from the vertebrae between L4 and S3. It is actually two combined nerves, the tibeal nerve and common fibular nerve, which branch out in the lower thigh area and continue distally to innervate the lower leg. Sciatica often is a result of two causes: a herniated disc or piriformis syndrome.

A herniated disc can result in numbness with tingling radiating pain down the back of the leg.

Piriformis Syndrome is basically tight lateral rotators which can compress the nerve & cause pain.

The lateral rotators can be stretched with the following poses:

Uttanasana: standing forward bend with thighs parallel or internally rotated

½ Pigeon: with bent leg pelvis supported on blankets

Modified ½ pigeon with bent leg on table or low counter top

Marichyasana 3: Sit on support and twist towards bend leg

Ankle to knee: Sit on support with one leg straight or bend both legs (one or two ankles to knees)

Modified ankle to knee: sit in chair and place one ankle over other thigh. Bend forward from hips

Badha konasana: feet touching & close to groins

Tarasana: extend feet about 18-42 inches from pelvis, lean forward from hips

Please note that and an MD should be consulted if sciatica is suspected or pain persists.

 

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.