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2 Today we will cover: Exercise for the back L-S spine S-I joint Pelvis

3 Toward Developing Scientifically Justified Low Back Rehabilitation Exercises Use evidence to support clinical programs. A neutral spine when spine is loaded is safest. ISSUES OF FLEXIBILITY Flexibility requires adequate strength and endurance first. Hip and knee flexibility are necessary.

4 Issues of Strength and Endurance Endurance appears to be a prerequisite for strength training. AEROBIC EXERCISE Important for reducing incidence and treating low back pain

5 Exercises for the Abdominal Muscles (Anterior and Lateral) and Quadratus Lumborum Curl-ups primarily activate the rectus abdominis. Sit-ups and leg raises increase psoas major activity and compressive loads on low back. Horizontal support increases activity of other abdominal muscles with little activity of psoas major.

6 Quadratus Lumborum Quadratus lumborum appears to be important as low back stabilizer.

7 Exercises for the Back Extensors Need exercise that activates extensors without excessively loading the low back Why?

8 To identify the correct seated posture, first sit in an extreme slouched position (a). Then, after a few seconds, slowly draw your back up straight and arch it (b). (Do not keep this position long; it can cause back strain.) Then, relax the arch in your lower back about 10% to find your correct posture (c). Work up to using this position as your normal seated posture.

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12 Should Abdominal Belts Be Worn? Evidence does not support use for exercise.

13 Notes for Exercise Prescription Frequency from three times per week to daily Avoid pain. Aerobic exercise Avoid full range movement with loads shortly after rising from bed. (why Hint: hydration) Emphasize endurance exercise over strengthening exercise. Improvement takes time.

14 L-S Spine

15 Lumbosacral juction-extension of the lumbar spine Forces on the Lumbosacral juction-why is this important? The lumbosacral junction and the L4 L5 junction are the most common sites of disc lesions in the low back lumbosacral junction is susceptible to anterior slippage of L5 on S1, a phenomenon known as spondylolisthesis An understanding of the forces generated at this joint complex helps explain the pathomechanics associated with these disorders

16 What are we going to cover today? Forces sustained at the Sacroiliac joints Forces on the sacroiliac joint are even less well studied than those on the lumbosacral junction. Because the joint appears to allow at least small movements, an appreciation of the forces exerted across the joint may improve the clinician s understanding of the pathomechanics of sacroiliac joint dysfunction

17 FORCES SUSTAINED AT THE LUMBOSACRAL JUNCTION (transitional zone) Lumbosacral junction is prone to injury, including disc lesions and spondylolisthesis. Loads on the joint contribute to pathology. Or, we can think of it as posture.

18 How much force does the L-S joint sustain? lbs lifting=22-33 lbs Compression load on the disc can range from lbs! Calculations of the joint moments and forces depend on the assumptions made in the model, including the size of the trunk and pelvis, the shape of the lumbar curve, and the muscles and ligaments included in the model as well as the movements of the spine that are studied.

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21 First, let s figure out your load forces Take your body weight x 112% Take your body weight x 240% Take your body weight x.70%

22 Two-Dimensional Example of the Analysis of Forces on the Pelvis while walking Simplified model predicts muscle loads of 112% of body weight and compressive load of 240% and shear forces of 0.70% body weight. Magnitude of compressive and shear forces is affected by size of load being lifted and orientation of the pelvis. Let s go to the lab paper-page 2.

23 Loads at the Lumbosacral Junction Current studies provide general approximations of loads on joint LOADS IN THE LUMBOSACRAL REGION DURING BENDING AND LIFTING-Review again- Estimated compressive loads range from 270 to 1,236 lb, and peak anterior shear from 90 to 270 lb. Estimates depend on assumptions used in model. Understanding the effects of posture and lifting techniques on anterior shear forces will help clinicians to develop effective treatment and prevention strategies. First page of lab: Effects of Hip Muscles on the Pelvis

24 LOADS ON THE LUMBOSACRAL JOINT DURING WALKING Loads smaller in walking than in lifting Peak in double limb support when pelvis is maximally tilted anteriorly

25 The S-I joint

26 FORCES SUSTAINED AT THE SACROILIAC JOINTS Overview of the Analytical Model of the Sacroiliac Joint Analysis is complicated by the number of unknowns. Please calculate your body weight x 1.1=

27 Sacroiliac Joint Forces from the Literature Loads from 0.85 and 1.1 times body weight reported during static single-limb stance. Walking appears to generate larger loads at the sacroiliac joint.

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29 MECHANICS OF PELVIC FRACTURES (think of loading and OA or Osteoporosis) Most pelvic fractures result from impact loading such as in motor vehicle accidents. Stress fractures can occur from repeated loading such as running or marching. Most common in narrowest part of pubic ramus

30 CLINICAL Importance: STRESS FRACTURES OF THE PELVIS Symptoms of pelvic stress fractures include groin pain, which is also a common symptom in individuals with chronic hip dysfunction. Practitioners may need to coinside the presence of pelvic stress fractures in small women, particularly Caucasian women, with complaints of groin pain and who exhibit no direct signs of hip dysfunction. A history of repeated loading, such as running, also is relevant