Case 1: L5 Spondylosis Flashcards
What is spondylosis?
Spondylosis is a minor stress reaction to a part of your back on the vertebrae, show on the model. Just like a stress fracture anywhere else in your body, it happens when we increase the load placed on that joint has recently increased. When your training went from 2 - 4 times a week could be a contributing factor.
Spondylosis rec time and activity management.
Spondylosis is usually fully resolved within 6-12 weeks. In the next few weeks, we will have to stop any high-load activities such as gymnastics and any weights. We can work together to find some other forms of exercise you might enjoy to keep you fit and activity over the short term few weeks. This could include swimming, cycling or nordic walking
Ax priorities of Spondylosis:
- Functional and observational
- AROM + Combined movements
- Manual Exam - Palp and PIAVMS
- Motor Control
- Other possible impairments
Ax Functional and observational tests/results
- Pelvic tilt in standing, anterior
- Gait - normal
- Single-leg stand - normal
- Single leg squat - Trendelenburg + IR in Right leg vs left
- Single leg hop - R leg pain
Ax AROM + Combined movements tests/results
Flexion- normal hands onto floor, no pain with overpressure
Ext - Apprehensive to move into extension. Reduced ROM and pain on EOR
Ext + Rot Right = sharp pain, reproduction
Ext + Rot Left = Normal
Sitting reduced Thoracic Rot ROM
Ax Manual Exam - Palp and PIAVMS tests/results
Manual Exam:
- Sidelying MMT glute med 4/5 Right side
- Palpation:
Very Tender Iliac crest and QL
Tender Midline L3-5 (2/10 pain)
Pain on palpation of R QL and ES muscles lumbar and into Thoracic
- PAIVMS
Central
L4 - 3/10 pain
L5 - pain replicated, sharp pain
rest normal
UL right
L4/5 + L5/S1 pain replicated, sharp and reactive
Ax Motor Control tests/results
4 point kneeling:
- Ability to find neutral Pelvic tilt
- Ability to sit back on heels with neutral spine/pelvic tilt
- arm and leg lift – extension at L5/S1 – able to correct with feedback
Prone hip Extension
- R side – hinge at L5/S1 and pain (3/10). - Able to reduce pain to 1/10 with instructions for TA.
Forward lean in standing
- able to do with feedback from mirror but only small range
Ax Other possible impairments test/results
Thomas test - Tight hip flexors
Weak Glute Med
Apart from your physiotherapy management, what else would you consider doing as part of the management of this patient?
- Consider diet – especially if bone density and weight are an issue – appropriate referrals Consider MDT re psychological conditions – if patient is experiencing these
- Discuss with coach regarding specific needs in modifying training
- Pain management strategies in the short term if this is an issue – periods of rest from standing, manual therapy (massage, self-massage etc).
What do you think the high levels of pain on palpation indicate?
Central sensitisation
Peripheral sensitisation
Local nociception
What are your 3-4 treatment priorities for treatment today?
- Advice + Education
- Motor Control Impairment
- Other underlying impairments
Tx - Advice + Education
What it is?
- Spondylosis is a minor stress reaction to a part of your spine, shown on model
What is it caused by?
- Load and stress on the bone, due to recent increase in training
How long is recovery?
- 6 to 12 weeks, meaning being able to compete is very favourable
Is the outcome favorable?
- Very favourable outcome if treated conservatively and appropriately
- Most important thing in the short term - next few weeks is that we stop any high-load activity like Gymnastics which was causing the stress, just to give it time to heal
- Can use other forms of exercise such as swimming, cycling, or nordic walking to stay active as they don’t specifically load the back but maintain fitness.
Important we continue to stay active and in a routine, if any other movement/activities are being impacted then we can work together to find a way to modify these so we can still do them
Tx - Addressing MC impairment Early
It is very important that we work on your motor control in rehab so that when we get back to our normal high-load exercise we can continue to have a strong core and good motor control. Just like we discovered from your PE, you tend to anteriorly tilt your pelvis, this isn’t a huge problem but we want to be able to accurately find our neutral pelvic position as this is the position that doesn’t place more stress onto your back. We can do a few exercises to help this, and over time we will continue to progress these and integrate them back into gymnastics
Exercises:
TEACHING TA Activation:
- Take a deep breath in and slowly exhale out of your mouth.
- As you exhale, draw in your lower abs and engage your pelvic floor muscles.
- You should notice your transversus abdominis contracting under your fingers. - Continue to breathe normally as you hold your belly in.
- Start in 4-point kneeling –with breathing control – moving arm and leg (as this could be achieved in the physical using feedback).
- Just like in the ax part we are going to continue working on this exercise, but we are going to isolate some of the movements to really ensure we are staying in a neutral tilt and activating our TA.
- 10 reps of arms, 10 reps legs, 10 together x 3 sets, 2 x Day. Only going to range where we start to feel pelvic tilting, slow and controlled movements - Prone hip extension with TA (if they can do without pain – this might need to be a progression)
- Perform 10 reps of 3 sets
- Squeezing your glutes and ensuring not to lift hips off the group
- Can progress to superman or exercise ball - Forward lean in standing
- find neutral pelvis
- hinging hips without moving knees
- move to the length that you can control and feel pelvis in correct position
- can progress to weighted, RDL, Deadlift, goodmornings - Posterior pelvic tilt in sitting (if the patient finds this difficult from the physical)
- Just like finding Neutral in 4 point kneeling, we can move in and out of pelvic tilt and find neutral, check with mirror
- repeat 10 times, 3 sets
- progress to standing - Glute Med – starting in standing – small squat with Tband around knees or crab
- walk or isometric Glute Med against wall – add a single leg squat.
- helps with strengthening glutes and also working TA
- Replicates more functional task in gym
Tx - Addressing other impairments
- Hip flexor length - stretching but not EOR
- Thoracic Spine mobility– thoracic mobilisation, foam roller, stretches in side lying (or sitting but careful not going to end range with lumbar).
Provide a BRIEF summary of the exercise (with progressions) for this patient over the next 8 weeks
Key progression ideas from the group:
* Progressing motor control (quite quickly if the patient is able to do them)
* Progressing motor control can include adding load, speed and complexity to the task
and
* reducing feedback and base of support. They can reduce feedback from the mirror
but still ‘check in’ that they are doing it correctly every 2nd or 5th rep for example.
* Hip extension in prone – add arm also (superman)
* Add plank for endurance (and side plank)
* Add squat/deadlift for load and control (and for strengthening)
* Continue addressing other impairments (Thoracic mobility and Glute Med strength) –
key
* progressions to Glute Med would be increasing load and speed – stepping off step,
single leg
* squat, increasing speed into eventually jump land
* Eventually motor control in standing that challenge extension – wood chop, throwing
* medicine ball or swiss ball overhead (eccentric control into extension). Jumping-
landing –
* using trampoline if possible to start with (lower load).
* Overhead press, overhead squat, maybe split squat with overhead press.
* Gradually return to sport (depending on symptoms and time) – providing guidance
around this
