When a concave surface moves on a convex the direction of translation (slide) is in the same direction as that of the motion (rotation). When a convex surface moves on a concave the translation is in the opposite direction to.
This article has been cited by other articles in PMC. Abstract. Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management.
The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy. Keywords: Diagnosis, Hypermobility, Low back pain, Physical examination, Segmental instability. The topic of chronic instability of the lumbar spine is subject to much debate as to the exact nature of the problem, the correlation with symptoms, or the relevance to patient management. Understanding the associated history may assist clinicians in better understanding current methods used to establish the diagnosis. The purposes of this paper are to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and summarize current research relative to clinical diagnosis. In particular, we endeavour to determine whether there are data to support the two concepts of mechanical and functional chronic lumbar instability and we explore the clinically oriented examination findings relevant to the constructs of chronic lumbar instability by examining relevant clinical diagnostic elements and the best clinical tests. Historical Perspective.
The concept of instability of the lumbar spine was first presented by Barr. The loss of disc height was thought to decrease restraint of passive stabilizers resulting in increased movement of vertebral segments. The loss of disc height subsequently decreased space between lumbar facet joints and adjacent vertebral bodies, placing additional stress on articular cartilage.
Augmented contact coupled with increased segmental motion was thought to adversely affect the joints and contribute to low back pain. Orthopaedic surgeons had already been using fusion to treat low back pain caused by lumbar disc degeneration, but this model further reinforced the rationale for lumbar fusion to treat low back pain. Although the use of therapeutic exercise for low back pain was described in the literature in the early 1. Muscle function around the lumbar spine of a weight lifter was calculated using a mathematical model developed by Farfan and Gracovetsky. Based on the model, it was suggested that the passive structures of the lumbar spine were better designed to resist compression and much less resistant to segmental shear forces.
Co- contraction of the abdominal wall and back extensor muscles provided stability against shear forces in the lumbar spine under load. This work provided additional rationale for physical therapists that muscle contractions could be used to increase stability of the lumbar spine.
In 1. 98. 2, the International Society of the Study of the Lumbar Spine held a conference on lumbar instability that included a number of experts from medicine and physical therapy. In the keynote address, Kirkaldy- Willis. Fig. 1). He proposed that discussions of instability at the conference should be directed toward three goals: agreement on the definition of instability, how instability could be diagnosed, and how treatment could be initiated based on the severity of instability.
During this conference, Pope and Panjabi. Stiffness was defined as the amount of motion within a system relative to a load applied to the structure. This would allow comparison of different responses in adjacent spinal segments to similar load applications, which they conjectured might be difficult to study in vivo.
Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Spinal adjustments were among many. Background. Osteopathic manipulative medicine texts and educators advocate a range of approaches for physical assessment and treatment, but little is known about their use by osteopathic physicians in the United States. Summit’s Orthopedic Physical Therapy Continuing Education (CE/CEU) Workshops / Seminars for Physical Therapists (PT/PTA), Occupational Therapists (OT/OTA), Trainers, Massage Therapists.
The loss of stiffness was thought to allow increased motion to occur at each vertebral segment. Flexion and extension radiographs could be used to identify and quantify increased end- range motion at lumbar spinal segments. Gertzbein et al. 8 provided evidence that in mildly and moderately degenerated spinal segments, motion was not thought to be excessive but rather erratic. Only 3. 3% of cadaveric spines with mild and moderate degeneration spinal segments demonstrated excessive range of motion based on flexion and extension radiographs. Compared to control spines, mildly and moderately degenerated spinal segments demonstrated changes in the instantaneous axis of rotation throughout flexion and extension. Identification and quantification of this motion in vivo was thought to be more difficult to obtain.
A subjective evaluation of instability from a manual physical therapist’s perspective was provided by Paris. He proposed a distinction between lumbar instability and hypermobility, which he defined as excessive movement at a joint given the subject’s age and activity. Since flexion and extension X- rays were not helpful in identifying instability, Paris proposed that they might be helpful in identifying hypermobility. Instability was defined as aberrant (erratic) motion during movement (shake, catch, or hitch; sharp angulation; uncoordinated muscle contraction) or the presence of palpable defect both in standing and in prone. He described hypermobility as a quantitative measure and instability as a qualitative measure. Thus, the defining difference between instability and hypermobility was the presence of what has been termed ‘aberrant movement’.
Aetna considers cervical laminectomy (and/or an anterior cervical diskectomy and fusion) medically necessary for individuals with herniated discs or other causes of spinal cord or nerve root compression (osteophytic spurring.
Panjabi presented his concept of spinal stability in two articles in the early 1. This article discussed the idea that stability of various joints in the body is maintained by a combination of the structural (passive) system, muscular (active) system, and the neural control system.
The interplay between these systems was thought to be necessary for neuromuscular control of spinal segments and disruption might lead to a lack of segmental control. Panjabi suggested that loss of osseoligamentous integrity would result in lack of stability of the spine if the muscular and neural control systems were unable to adequately compensate. The ability of the patient to maintain an efficient coordination between these systems would allow him or her to function without undue stress on the tissues in the body. Literature Search Process.
A literature search was undertaken to review the published work on instability since the publication of the symposium papers in 1. In particular, literature was screened for the association with the questions posted previously. The first search used the MESH terms lumbar, vertebrae AND instability, joint in Pub. Med. The retrieved articles were saved in a Reference Manager.
TM database. In order to find all relevant articles, multiple searches were performed. The second search was performed in CINAHL with lumbar vertebrae AND instability. The results were combined in the database to look at the presence of duplicates. A third search was performed in Pub. Med using the MESH terms ((((Lumbosacral Region [Mesh] OR Lumbar Vertebrae [Mesh])) AND Joint Instability [Mesh]) AND (Diagnosis [Mesh] OR diagnosis [Subheading] OR Diagnosis, Differential [Mesh] OR radiography [Subheading])). This returned 2. 96 citations, which were combined in Reference Manager to determine the presence of duplicates.
A fourth search used the MESH terms ((((Lumbosacral Region [Mesh] OR Lumbar Vertebrae [Mesh])) AND Joint Instability [Mesh]) AND (Diagnosis [Mesh] OR diagnosis [Subheading] OR Diagnosis, Differential [Mesh] OR radiography [Subheading])) AND Physical Therapy (Specialty) [Mesh]. This returned only one article. This was added to the database. A link- out was performed in Pub. Med and returned 1.
The citations were combined in Reference Manager, and duplicates were identified and deleted. Surgical or post- surgical references were also eliminated. A second author (MM) scanned the same references to determine appropriateness for inclusion in the literature review.
The articles were then assessed as to whether the authors had used a method of statistical analysis to determine the presence of instability relative to a radiological standard (flexion–extension films). This resulted in fewer than 5. Are There Data to Support the Two Concepts of Chronic Lumbar Instability?
Mechanical. A number of studies published since the symposium have focused on the relevance of radiographic findings, including X- rays and magnetic resonance imaging (MRI), for the diagnosis for mechanical instability. The use of flexion–extension X- rays is relatively common, but the ability to identify instability has had mixed findings. The use of side- bending X- rays is thought to provide minimal additional information related to the amount of angular motion and instability. The use of MRI to assist in diagnosing lumbar spine dysfunction has increased in the past two decades. The degree of disc degeneration, using standard MRI, is not thought to correlate with the amount of angulation (> 1.
Findings have differed when dynamic MRI is used to examine motion in a standing position. The degree of disc and facet joint degeneration has a positive association with excessive translational motion while the degree of facet joint degeneration has a negative association with excessive angular motion.
These findings are similar to a previous study that indicated that zygapophyseal (facet) joint oedema was associated with the presence of instability on flexion–extension radiographs. Other spine pathology such as annular tears (+LR = 6. LR = 0. 8. 3) or traction spurs (+LR = 6. LR = 0. 8. 9) identified using standard MRI has also been associated with segmental instability (> 3 mm translation) on X- ray. It does appear that with more severe disc degeneration (grade V), there is a lesser amount of excessive angular and translational motion when compared to lower grades of disc degeneration.