Deep lumbar spine & disc anatomy

The best post on internet I have found related to lumbar spine & disc anatomy. Offered by Dr. Douglas M. Gillard, DC, Associate Professor of Clinical Sciences, Published Spine Researcher.

Sports Hernia Repair Protocol

Athletes who suffer from sports hernia use the following treatment protocol recommended by sports hernia surgeon Jeffery Hoadley, developed in conjunction with Scott Kneller, the Atlanta Falcons PT, DPT and Rehabilitation Coordinator, and Cara Yano, MPT at Atlanta Sports Medicine and Orthopedic Center.

Lower back pain and pelvic tilt during biking

I was always wondering what it the correct position for all my joints during biking. What can be the most energy efficient and at the same time anatomically less stressful position I should have.

Here is a wonderful website that gives nice detailed guidelines and rules of thumb for proper body position during biking.

I found very relevant to my problem the following information:

Lower Back Pain and Pelvic Tilt

This image shows two cyclists, with the one on the right in a far lower, more aggressive position. One might imagine that of the two, he might suffer more back pain. But this was not the case, with the cyclist on the left suffering debilitating pain, very quickly into a ride. The clue is in the angle of the pelvis. The rider on the left has a noticeable hinge point in his lower back as his pelvis is reluctant to lean forwards and the lower lumbar vertebrae appear to be immobile. The rider on the right meanwhile has a smooth transition from pelvis to lumbar region and along the whole spine. In the left hand case, the saddle was too low and the rider had a very stiff right hip joint. The excessive upwards movement of the knee and lack of mobility in the hip combined to push the pelvis back.

Spinal cord neurodynamics

A very interesting subject in neurodynamics is the points of convergence of neural tissue. In simple words, these points are the places in the body where two sides of the the neural tissue cord (either in the spinal cord or in the peripheral nerves) come closer to each other. This is happening when the therapist is extending of flexing the limbs or the spine. And this technique is believed that can play a major role in cases of pain due to nerves' compression somewhere along their course.

The following part is a very short part of Chapter 2 summary of “Clinical Neurodynamics” by Michael Shacklock. You can find a short summary of the whole chapter here, or you can buy the book here.

The spinal cord tends to move towards various specific segments. These areas are termed zones of convergence, and these areas include C5-6 and L4-5.  For example, tissues above C5-6 will slide toward this zone, as will tissues below this segment. The midpoint at which tissues diverge is at T6. At this point, tissues below T6 will converge towards L4-5, and tissues above T-6 will converge to C5-6.

Foot drop: L4/5 root or peroneal nerve?

Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, damage to the peroneal nerve or paralysis of the muscles in the anterior portion of the lower leg.

Possible lesion sites causing foot drop include (going from peripheral to central):

• Peroneal nerve - common, deep or superficial;
• Sciatic nerve;
• Lumbosacral plexus;
• L5 nerve root - herniated disc;
• Spinal cord - poliomyelitis, tumor;
• Brain (uncommon, but often overlooked) - stroke, tumor;

Other causes of foot drop are diabetes, trauma, motor neuron disease (MND), adverse reaction to a drug or alcohol, neuromuscular disease, and multiple sclerosis.

The challenge for a Physical Therapist is to differentiate between the orthopedic causes; in other words, to find the location of entrapment or trauma. Is it distally or proximally to the spinal cord? The diagnosis of diabetes, MND, and the rest of the systemic causes are the subject of another discussion.

The main question a Physical Therapist should put to himself is the following, as commonly discussed in literature: is this problem a radiculopathy or a neuropathy?

1. Radiculopathy: involves one spinal nerve root distribution following the patterns of a myotome and/or a dermatome.

2. Neuropathy: usually involves one peripheral nerve branch entrapped somewhere along its course.

Here are some general principles you could follow in such case:

1. Radiculopathy

Motor examination

• Remember that one root supplies more than one peripheral nerves innervating many muscles
• Muscle weakness is partial or incomplete
• Atrophy is quite rare
• Fasciculations are very rare
• Reflexes depressed or absent early

Sensory examination

• Sensory distribution of spinal nerve roots overlap
• Total sensory loss virtually never occurs

Pain

• Common history of pain proximally to the spinal cord
• Pain radiates down to the limp
• Traction of the spinal segments relaxes pain
• Compression of the spinal segments reproduces pain

EMG quite sensitive and posterior paraspinal muscles affected

2. Neuropathy

Motor examination

• Muscle weakness usually complete
• Worse with use, better with rest
• Early atrophy
• Fasciculations are common
• Rare reflex changes - depends on location of entrapment

Sensory examination

• Sensory distribution of peripheral nerve branches are discrete

Pain

• Rarely pain around the spinal cord
• Pain may be around the joint
• Compression or stretching of the nerve reproduces pain

EMG usually normal and no posterior paraspinal muscles affected

You can see a very useful video on lower extremity nerve root and peripheral nerve sensory differentiation below:

Furthermore, there is a great presentation by Adam P. Smith, MD, on www.auroramed.com. You can find it here. This presentation is on the cervical spine level, but the logic is the same. Read also the cases presented; they very interesting.

In the case of the dropping foot, treatment for some can be as easy as a foot-up ankle support (ankle-foot orthoses). A cuff is placed around the patient's ankle, and a hook is installed under the shoelaces. The hook connects to the ankle cuff and lifts the shoe up when the patient walks.

Pelvic organ prolapse: physical therapy or surgery?

Pelvic organ prolapse arises when one or more pelvic organs (i.e. bladder, uterus, rectum) descend into the vagina from their normal positions. It can be triggered by a variety of factors, including childbirth, obesity and menopause. Prolapse affects up to 50 percent of women at some point in their lives.

Many women prefer to forgo prolapse surgery and look instead to physical therapy.

Introduced in the 1990s, transvaginal mesh was intended to permanently fix pelvic organ prolapse (POP) and stress urinary incontinence — conditions that typically plague older women after a hysterectomy or menopause. Pelvic prolapse occurs when a woman’s pelvic muscles weaken and the pelvic organs — including the bladder, rectum and uterus — drop into the vagina. SUI occurs when everyday activities place pressure on the bladder. To fix these conditions, a hammock-like piece of synthetic mesh is surgically implanted transvaginally, or through the vagina, to support the pelvic organs.

However, transvaginal mesh has several well-known complications such as organ perforation and erosion. Some of the less severe problems include constipation and urinary incontinence. 

There are a few steps you can take to get started along this path:

1. Understand the Pelvic Floor

The pelvic floor spans the area under the pelvis, and comprises muscle fibers of the coccygeus, levator ani, and relative connective tissue. The pelvic floor separates the perineal region from the pelvic cavity. Please have a look at this article I have already posted.

2. Visit and ask the advice of a Medical Doctor you trust

Always visit a Medical Doctor you trust and ask his advice. It is important for you to get all the required information, examination and testing related to this problem. A trained Medical Doctor, mainly a Urogynecologist, has this knowledge and the experience to help you in this difficult decision.

3. Ask a Physical Therapist

As the MD will probably advise you, exercising your pelvic floor muscles is of the most important things you can do. Find a trained Physical Therapist you trust, give him/her all the required information he/she will ask you and follow his/her treatment plan.

A few exercises a professional may take you through* are:

• Straight leg raises (SLRs)
• Squats
• Posture therapy
• Kegel exercises

Therapists may also use biofeedback. This involves using a monitoring device with sensors placed either on your skin or inside your rectum or vagina. As you perform an exercise, a screen displays the strength of each contraction, as well as whether you’re using the proper muscles.

*Please consult a professional before attempting any of the exercises listed.

4. Consider All Options

Although surgery for prolapse can be the right choice for many women, it can be a last resort for others after they have exhausted alternative treatments. A large reason for avoiding prolapse surgery could be because of the less-than-favorable buzz surrounding transvaginal mesh, a hammock-like polypropylene plastic piece of material implanted through the vagina to support pelvic organs.

Sounds great in theory, right? Sadly, however, this mesh has been eliciting a slew of lawsuits over the complications arising for a number of women who have had it inserted transvaginally. According to the Food and Drug Administration (FDA), these complications have included organ perforation, vaginal erosion, and infection, among others.

If you do require surgery, talk to your doctor about solutions that do not involve transvaginal mesh.

An what does the American Urogynecologic Society say about these?

This article was created by me and Jen Juneau. Jen Jeneau is a content writer for Drugwatch.com. She is versed in technical writing, creative writing and everything in between.

Pelvic drop in running

I have already posted an article with some studying tips and a file I have created with all the muscles of the lower extremities with origin, insertion, action and innervation. One of the first pathologies we learn in our education is a dropping pelvis due to weak hip abductors. A pathology that can be tested with the Trendelenburg test.

In this video you can clearly see a dropping pelvis while an athlete is running. Keep in mind that the week abductors are always on the side of the leg that touches the ground at the specific moment. In this case, it appears that both sides are affected.

Change in load on L3 disc

Within the lumbar spine, different postures can increase the pressure on the intervertebral discs. Studies of intervertebral pressure changes in the L3 disc with changes in posture were performed and concluded in a table similar to the above one. The pressure in the standing posture is classified as the norm, and the values given are increases or decreases above or below this norm that occur with the change in posture (Magee DJ. Orthopedic physical assessment, 5th ed. Alberta: Saunders Elsevier; 2007).

Exercises after a chest and/or an abdominal surgery

A lot of times, Physical therapy is indicated after a chest or abdominal surgery. Here is a very nice video presenting some good and easy exercises to start with (and always together with a Physical Therapist to avoid dangers of injury or wrong posture) after such a case.

The effect of sitting on your hip muslces

Technology and internet in our era has brought a lot of new ideas into life and has made it more fun and easier than it was before. We all love spending hours in front of our screens surfing on the web, watching our favorite YouTube videos, socializing on Facebook. or even writing articles on our favorite blog (;-).

We all know the negative effects of the sedentary life, but thank to the explosion of the health awareness movement the last years, more and more people have started changing their life style towards a more active way.

What I am presenting in this article is the effect of this sedentary life on 2 very important for a strong and healthy spine muscles - the iliopsoas and the gluteus maximus. I have already posted an article on the tendency of iliopsoan to become short and tight and the gluteus maximus to become weak (the lower cross syndrome).

Let's have a picture of these 2 muscles:

       

picture 1. iliopsoas             picture 2. gluteus maximus

It can be easily pictured, that when we sit and our hips are in flexed position, the iliopsoas muscle is in a shortened position, while the gluteus maximus is in a stretched position. This fact creates a major problem other than the obvious effect on our muscles - inequality in the pelvis position.

As it can be seen in the pictures above, both muscles originate from the pelvis. The "iliacus" part of the iliopsoas originates from the fossa iliaca and the gluteus maximus originates from the facies glutea. This means, under certain circumstances, that they both have an effect of the position of the pelvis. The iliopsoas muscle, if contracted in the standing posture, it has the fixed part on the femur and the mobile part on the spine and the pelvis. This causes a forward tilt of the pelvis. On the other hand, the gluteus maximus, if contracted in the standing posture, it has its fixed part on the femur and the mobile part on the pelvis. This causes a backward tilt of the pelvis.

As a result of all these, a shortened iliopsoas muscle and a weak gluteus maximus muscle cause a forward tilt of the pelvis, which consequently leads to a compensating hyper-lordosis of the lumbar spine. And it is this hyper-lordosis that can cause quite a few problems if it is not treated properly and soon - chronic low back pain, herniated nucleus pulposis, spondylolisthesis, sponylolysis etc.

There is also a very well know theory/approach by Dr. Vladimir Janda about the tendency of some muscles to become weak and some others to become tight.

What is important for a Physical Therapist to know after that, is some specific stretching exercises for the iliopsoas and some strengthening exercises for the gluteus maximus.

Iliopsoas stretching exercises:

    

Here are two typical stretching exercises one can do for the iliopsoas muscle, always with after the assessment of a Physical Therapist and with his/her assistance. In the both pictures, the left iliopsoas is stretched. It is of extreme importance for someone to do these exercises under the guidance and supervision of a Physical Therapist in order to avoid wrong posture, further tissues damage or lumbar spine hyper-lordosis.

Gluteus maximus strengthening exercises

Research presented in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) presented the best exercises for the gluteus maximus. The authors of this particular study used electromyography (EMG) to quantify and compare signal amplitude as the gluteus maximus (and gluteus medius) fired in order to determine which therapeutic exercises most effectively recruit the glutes.

The result is that the 3 following exercies are the most effective:

One-leg squat - click for the JOSPT video

One-leg deadlift - click for the JOSPT video

Sideways, front, and transverse lunges - click for the JOSPT video

Proper lifting for new moms

Jen DeLorenzo, PT, CFMT, discusses challenges facing news moms including proper body mechanics and how a physical therapist can help them adjust their posture and lifting technique to avoid pain and injury. To find a PT near you, visit www.moveforwardpt.com.

Common postural diviations

Spine health: trusted information for back pain and neck pain relief

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This site has been developed by a multi-specialty group of medical professionals. It will be continually enhanced with new features, and we will base its direction and future developments primarily on your feedback (please see contact us) to send in your suggestions.

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Factors that favor a herniated nucleus pulposus in the L spine

1. Preexisting disc degeneration with tears in the posterior annulus that allow a path for the flow of nuclear material

2. Sufficiently hydrated nucleus capable of exerting high intradiscal pressure

3. Inability of the posterior annulus to resist pressure from the migrating nucleus

4. Sustained or repetitive loading applied over a flexed and rotated spine

source: Donald A. Neumann, Kinesiology of The Musculoskeletal System, Foundations for Rehabilitation

The importance of pelvic nutation

The relatively small and poorly defined rotational and transnational movements that occur at the sacroiliac joint in the sagittal plane are called nutation and counter-nutation.

These movements perform two major functions, based on Donald A. Neumann, Kinesiology of The Musculoskeletal System, Foundations for Rehabilitation.

1. Stress relief within the pelvic ring

2. Stability during load transfer

Regarding the first function, I have created this flowchart in order to make it understandable:

walking --> reciprocal flexion-extension pattern --> out of phase pelvic rotation --> tension in muscles and ligaments --> oppositely directed torsion --> nutation/counternutation --> stress dissipation (stress that would otherwise occur in the pelvic ring it it were a solid structure).

Regarding the second function, it is important for us to realize that nutation is the closed pack position for the SI joint. This means that the majority of joint structures are under maximal tension in this position, thus the joint is more stable. Consequently, torques that favor nutation help stabilize the SI joint. These are: gravity, stretched ligaments and muscle activation.

Gravity: the body weight line passes vetrally to the sacrum causing a forward tilt & the femural head reaction force on the acetabulutm causes an iliac bacward tilt.

Stretched ligaments: interosseous and sacrotuberous ligaments stretch the joint when movement occurs.

Muscle activation: the following muscle make the sacrum to titl forward (S) or the iliac crest to move backward (I) or just stabilize the SI joint:

erector spinae (S)
multifidus (S)
rectus abd. (I)
obliq. abd. int. & ext.
transv. abd.
hamstrings (I)
gluteus max. (I)
lat. dorsi
iliacus (S)
piriformis

Pelvic floor anatomy & exercises

Maybe we think that pelvic floor muscles are not important in Physical Therapy, but watch these two videos and you will find out how crucial can be for pelvic stability and general health condition.

Treatment guidelines: low back pain (2)

I have already presented the treatment guidelines for low back pain from the Royal Dutch Society for Physical Therapy (KNGF).

Now I am presenting the New Zealand Acute Low Back Pain Guide by the The Accident Compensation Corporation (ACC) in New Zeland.

ACC provides comprehensive, no-fault personal injury cover for all New Zealand residents and visitors to New Zealand.

How to do proper sit ups

There are thousands of books on how to work with your abdominal muscles and which are the best exercises for them. However, only properly educated physiotherapists or trainers should give exercises for the abdominal exercises to people, especially when they are recovering from an injury or a disease.

This article is not about showing more types of exercises, but about explaining how a proper sit up exercise should be performed.

With the body in supine position, 3 major points are about to be analyzed: 1. flexion of the thoracic level, 2. flexion of the knees, 3. reciprocal inhibition of the iliopsoas muscle.

A little bit of anatomy

It is important for us to realize the origin and insertion of all our abdominal muscles - the obliquus externus, the obliquus internus, the transversus abdominis, the rectus abdominis,  and the quadratus lumborum (I am not mentioning the pyramidalis, since it does not play a major role in the flexion of the rest of the abdominal muscles).

In the picture above, we cannot see the quadratus lumborum, but this muscle is very deep in the abdominal wall, originating from crista iliaca and inserting to rib 12, and process costalis of L1-L4 vertebrae. You can find more on that in your anatomy book.

The main function of the abdominal muscles is a. the flexion (forward bending) of the trunk against the gravity in the standing posture (our legs fixed) or b. the flexion of our hips in the hanging posture (our trunk fixed). It is very important to realize this "against the gravity" note, because a lot of people thing that when we bend forward while in standing position we use our abdominal muscles, which is not true. When we bend forward while in standing position, it is the gravity that is creating this movement and the back muscles that are activated eccentrically that hold us from falling down.

So, we can understand, that the only way to work with our abdominal muscles is by laying down and start lifting up our trunk with our abdominal muscles against the gravity.

There are also other muscles with the same function - the iliopsoas and the rectus femoris.

It is very important to understand that these muscles are also flexing our trunk (with legs fixed) or flexing our hips (with trunk fixed), because we need to inactivate them and isolate the abdominal muscles when we do the sit ups. In other words, we must be careful when we do sit ups not to work with our iliopsoas or our rectus femoris instead of the abdominal muscles due to wrong posture.

But how we can properly do that? Is it right to lay down completely straight and start doing sit ups? Should we bend our knees? Why? Would it be better to lift them up, above our pelvis? Why? Should we better ask someone to hold our feet on the ground? Or should we better ask him to pull our heels against us while we do the sit up?

Let's try to answer these questions.

In doing the sit ups, as we saw before, we need the isolate the abdominal muscles from the iliopsoas and the rectus femoris. And there are 3 completely safe ways to do that, that every physiotherapist and trainer should be aware of:

1. Flexion of the thoracic level

While doing the sit ups, we should flex only the trunk till the thoracic level, without lifting up the lumbar spine. This way, the abdominal muscles are activated completely. If we try to lift up the lumbar spine, then the iliopsoas is activated and is putting a lot of pressure on the lumbar spine vertebrae, which is quite dangerous, especially in patients with untrained abdominal muscles.

2. Flexion of the knees

By flexing the knees, we bring the biggest percentage of your center of mass above your pelvis or better, above the axis of rotation for the flexion movements of the abdominal muscles. This way, our muscles in the rest of the body are relaxed since we are not trying to hold our legs down on the ground, which we would try to do if we had our legs straight and the center of mass under the axis of rotation for the sit ups. Also, in this posture we rest the lumbar spine my flattening the normal lordosis and putting less pressure on the inter-vertebral disc.

3. Reciprocal inhibition of the iliopsoas muscle

What we must try to do during the sit ups is to inactivate the iliopsoas and the rectus femoris. There are 2 ways to do that:

a. lifting up the legs from the ground. This way, the iliopsoas and the rectus femoris are "loosing" their fixed point (the ground) and they are completely inactivated.

b. bend our knees, keep touching the ground while asking from someone to pull (and NOT hold on the ground) our heels towards him. This way, the gastrocnemius and the hamstrings become active and the iliopsoas and rectus femoris become inactive due to the reciprocal inhibition effect.

So, next time someone asks you to hold his/her feet on the ground while he/she is doing sit ups, do NOT do it :-)

Lower cross syndrome - anatomy

Ok, we all know this diagram. What I was interested in doing, though, was to find the exact muscles that are important in this syndrome. So, I am presenting them with origin, insertion, action and innervation:

Go to this link.

Lumbar spine assessment - a complete guideline

One of the most complete online guidelines for the lumbar spine assessment, broad to us by 3 ESP students of the Hogeschool van Amsterdam - Julie and her two Sara’s.

"The goal of the website is to guide students during the assessment of certain lumbar spine conditions. Therefore, we advise you to first take a look at the anatomy of the lower back to understand the conditions and gain sufficient knowledge on the subject.

The examination page talks about the general examination of the low back, including general patient history, observation as well as active and passive range of motion (ROM) and neurological testing.  This page insures you get the general knowledge you will need to assess a patient with low back problems.

Next to a-specific low back pain and malingering, the website includes lumbar spinal stenosis (LSS), disc herniation, lower crossed syndrome, lumbar instability and scoliosis as low back pathologies. All these conditions are described and subdivided into the different examination parts: patient history, assessment and treatment. The first two subcategories tell you what you should look for/what you might find in a patient with that specific pathology; questions you should ask, what tests to do and what the findings might be. Also in the assessment parts, different assessment tests will be mentioned. When clicking on the test, a link will forward you to the video of the test. The video will show how to perform the test with explanations. The treatment part is only a treatment suggestion and should only be taken as an orientation".

source: http://lumbarspineassessment.wordpress.com