Two weeks ago, for a cable special on yoga for seniors, I was interviewed at Staten Island University Hospital along with 2 current and one former patient. Each of us was interviewed and the students very eloquently discussed the reasons and health considerations that brought them to yoga. Some memorable moments included Josephine reporting that she was so “brainwashed” by the surgeons, regarding the hip precautions following her total hip replacement, that she has had to slowly unlearn them again to equalize her hamstring length. Mary, very politely stated that her daughter (an OTR/L and colleague) had suggested she begin yoga because she had a “hunchback”, and Irene, who did yoga in inpatient rehab, said when she did yoga she just “felt better”.
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.
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.
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.
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.