Intervertebral Discs lie between the vertebrae. There are 23 discs which account for approximately 20-25% of the length of the spinal column. There are 6 in the neck, 12 in the middle back and 5 in the lower back. The fluid, gelatinous inner part of the disc is the nucleus pulposus, and is confined by a fibrous ring called the annulus fibroses. Disc herniation occurs when the disc gets squeezed and the core leaks out of the outer ring and pushes on the spinal nerve roots. Posterolateral herniations are often caused by excessive flexion/rotation and account for approximately 90-95% of herniations with 95% of those are between the L4-L5 or L5-S1. IV discs become circumferentially broader when the spine is compressed and thinner when stretched (as in hanging or suspended).
Forward flexion and rotation can create disc shearing. End range flexion because it can force the disc more posteriorly.
Herniated Discs respond to extension and may be worsened with flexion. This is opposite about 5-10% of the time and flexion is good for herniated discs which have an anterior herniation. Build core strength with a focus on the multifidious muscles which stabilize the vertebrae and attach to the spinal process.
The canal of the spinal cord can narrow from osteoarthritis and/or other degenerative changes which restrict the space for the spinal cord and spinal nerves as they exit the canal. Cervical and lumbar stenosis are the most common.
Indications: Flexion, Core strength, Posterior pelvic tilts
The forward slippage of one vertebrae over another one. There are 1-4 progressive grades with grade 4 having a 75-99% slippage. It can be age, injury and trauma related. Surgery is recommended with slippage over 50%.
Contraindications: avoid lifting, bending, and sports.
Indications: Develop core strength with deep abdominal muscles and paraspinal muscles to stabilize the spine. Improve muscle balance to maintain good posture.
Spinal fusions are procedures whereby vertebrae are fused together to form one larger, less moveable bone. The vertebrae are immobilized with screws and/or small plates, and often rods, screws or plates are attached to the vertebral pedicles to stabilize the fusion and enhance new bone growth. There are several approaches to spinal fusions: anterior, posterior and lateral.
A brace may be worn after surgery for up to 3 months when the patient is out of bed. Patients are allowed basic exercises, including routine walking, during the first several weeks after surgery.
Contraindications: Avoid range of motion at fusion level, bending, twisting, or lifting anything heavy until bony fusion process established, approximately 3 months. Lifting and activity restrictions will be gradually removed as the healing process takes place.
Indications: Rehab focuses on core stabilization, pelvic strengthening, leg stretches, dynamic balance and postural retraining. Two important concepts are the 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.
Total Hip Arthroplasty:
Advantages: don’t have to cut through muscle, no hip precautions, lower rate of dislocation. Disadvantage: may lack hip extension.
Posterior approach: Higher rate of hip dislocation. Hip Precautions last approx. 4-12 weeks : no femoral internal rotation or adduction beyond neutral, no hip flexion beyond 90 degrees.
Lateral approach: Advantages: good exposure of acetabulum, low risk of hip dislocation (no damage to post capsule or short external rotators). Disadvantage: less femur visualization, hip abduction weakness.
Hemiarthroplasty: femoral head articulates with acetabulum.
Total Knee Arthroplasty:
516,000 in 2006, 3.48 million by 2030. TKR’s last approx. 90% 10 years and 78% 20 years. Aggressive PT is required with an emphasis on regaining as much active flexion as possible.
Transfers (all done towards stronger side initially):
1) Sit to stand (with arms and without)
2) Chair to floor (2 techniques)
3) Floor to chair (2 techniques)