Advanced Physical Therapy Techniques for Spinal Disorders

Dr. Maha Alibeiny’s lecture has three parts: (1) Mechanical Diagnosis and TherapyMDT (McKenzie)A system of assessment, diagnosis and treatment for the spine and extremities that classifies patients by clinical presentation and relies mainly on self-treatment. (MDT / McKenzie), (2) Core stabilityCore stabilityThe ability to control the position and motion of the trunk over the pelvis and leg, so force and motion can be produced, transferred and controlled in kinetic chain activities., and (3) Spinal tractionSpinal tractionTraction forces applied to the cervical and lumbar spine through mechanical systems such as tables, pulleys, cables and weights, to treat neck and back pain..

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Part 1 — Mechanical Diagnosis and Therapy (MDT)

Objectives

• Describe the MDTMDT (McKenzie)A system of assessment, diagnosis and treatment for the spine and extremities that classifies patients by clinical presentation and relies mainly on self-treatment. approach.
• Understand the basic MDT syndromes.
• Differentiate centralizationCentralizationSymptoms moving proximally, toward the spine. A good sign. from peripheralizationPeripheralizationSymptoms moving distally, away from the spine and down the limb..
• Identify the clinical picture of each syndrome.
• Recognize the MDT exercises for lumbarLumbarRelating to the lower back, the part of the spine between the chest and the pelvis.General meaning, not from the slides disorders.

What MDT is

• Developed by New Zealand physiotherapist Robin McKenzie (1931–2013) in the late 1950s; launched as “Mechanical Diagnosis and Therapy” in 1981.
• A system of assessment, diagnosis and treatment for the spine and extremities.
• Classifies patients by clinical presentation, not by anatomy.
• Relies mainly on self-treatment; it minimizes manual therapyManual therapyHands-on treatment by the therapist, such as joint mobilization or manipulation.General meaning, not from the slides. The therapist adds passive procedures only if self-treatment isn’t fully effective.

Centralization

The slide figure shows a progressive centralization process with an appropriate exercise programme: leg pain retreats step by step from the foot, up the leg, to the buttock and finally to the spine. Centralization = symptoms moving proximallyProximalCloser to the trunk or the point of attachment of a limb; proximally means in that direction.General meaning, not from the slides (a good sign); peripheralization = symptoms moving distallyDistalFarther from the trunk or the point of attachment of a limb; distally means in that direction.General meaning, not from the slides (see W2-L2).

McKenzie’s three syndromes

Quick sort: only derangement refers pain down the limb and can centralize. Postural = normal tissue overloaded by sustained end-range; dysfunction = short tissue stretched at end-range.

McKenzie techniques (slide figures)

• Prone extension sequenceProne extension sequenceA McKenzie progression: prone over two pillows, one pillow, prone lying, prone on elbows, then prone press-up. (Box 4-9): proneProneLying face down.General meaning, not from the slides over two pillows → one pillow → prone lying → prone on elbows → prone press-upPress-upLying face down and pushing the upper body up with the arms while the pelvis stays on the surface.General meaning, not from the slides; plus standing backward bending.
• Lateral shift correction: the patient’s thorax is shifted (e.g. toward the right, pelvis to the left). The therapist applies a lateral glideLateral glideA sideways sliding movement of the trunk over the pelvis.General meaning, not from the slides: pressure against the patient’s elbow and thoracic cageThoracic cageThe rib cage: the ribs, breastbone and the thoracic part of the spine.General meaning, not from the slides while pulling the pelvis the opposite way.
• Self-correction of a lateral shift: hands on the hips, the patient glides the pelvis back under the trunk.
• McKenzie exercises: 1–4 = extension (prone lying, prone on elbows, press-up, standing extension); 5–6 = flexion (knees to chest in lying, sitting flexion).
• Dynamic loading strategies: flexion in standing, extension in standing, flexion in lying, extension in lying, side glide in standing, therapist-assisted side glide.
• Techniques to increase lumbar extension (prone press-up, standing) and lateral flexibility (stretching the concaveConcaveCurving inward, like the inside of a bowl.General meaning, not from the slides side of the curve in various positions).

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Part 2 — Core Stability

Objectives

Define core stabilityCore stabilityThe ability to control the position and motion of the trunk over the pelvis and leg, so force and motion can be produced, transferred and controlled in kinetic chain activities.; the three systems; globalGlobal musclesSuperficial muscles with larger mass and longer moment arm, which produce gross trunk motion and force. vs localLocal musclesMuscles with smaller mass and shorter moment arm, which give segmental stability, coordination and control. muscles; the thoracolumbar fasciaThoracolumbar fascia (TLF)A multi-layered fascial system that surrounds the erector spinae, multifidi and quadratus lumborum and supports them when they contract.; cervicalCervicalRelating to the neck, the top part of the spine.General meaning, not from the slides muscle control; neural control; effects of limb function; the Valsalva manoeuvreValsalva manoeuvreForcefully breathing out against a closed airway, which raises pressure in the chest and abdomen.General meaning, not from the slides.

Definition

There is no universally accepted definition of “core”, “core stability” or which muscles form the core. The working definition:

Core stability: the ability to control the position and motion of the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segmentSegmentalRelating to a single spinal segment: one vertebra and the structures linked to it.General meaning, not from the slides in integrated kinetic chainKinetic chainA series of linked body segments, with their joints and muscles, that work together to produce movement.General meaning, not from the slides activities.

Three major systems of core stability

Bergmark’s muscle classification (1989)

Note how QL and internal oblique appear in both columns: their lateral part is global, their medial/fascialFasciaA sheet of connective tissue that wraps around muscles and other structures.General meaning, not from the slides part is local.

Stabilizing features: global vs deep segmental

Guy-wire figure: the global muscles give overall stability against perturbationPerturbationA disturbance or push that knocks the body off its steady position.General meaning, not from the slides like the guy wires of a mast. But they can’t control a multisegmental spine on their own: compression from the long guy wires stresses the inert tissuesInert tissuesTissues that cannot contract, such as ligaments, joint capsules and discs.General meaning, not from the slides at the end-rangeEnd-rangeThe very end of a joint's available movement.General meaning, not from the slides of an unstable segment. Deep muscles attached to each segment provide segmental stability.

Thoracolumbar fascia (TLF)

• A multi-layered fascial system that surrounds the erector spinae, multifidi and quadratus lumborum, supporting them when they contract.
• Bigger muscle bulk → more fascial tension → more stability.
• The latissimus dorsiLatissimus dorsiThe broad muscle of the back that pulls the arm down and back.General meaning, not from the slides aponeurosisAponeurosisA flat, sheet-like tendon that attaches a broad muscle.General meaning, not from the slides and fibres of serratus posterior inferiorSerratus posterior inferiorA thin muscle on the lower back that attaches to the lower ribs.General meaning, not from the slides, internal oblique and transversus abdominis blend at the lateral rapheLateral rapheThe seam at the side of the back where the layers of the thoracolumbar fascia and abdominal muscles join.General meaning, not from the slides; their contraction tensions the angled fascia and stabilizes the lumbar spine.
• The “X” design (serape effectSerape effectThe 'X' design: the superficial layer of the TLF links the latissimus dorsi with the contralateral gluteus maximus, stabilizing the lumbosacral junction.): the superficial layer of the TLF links the latissimus dorsi with the contralateralContralateralOn the opposite side of the body from the structure being discussed.General meaning, not from the slides gluteus maximusGluteus maximusThe large buttock muscle that extends the hip.General meaning, not from the slides, stabilizing the lumbosacral junctionLumbosacral junctionThe point where the lumbar spine meets the sacrum.General meaning, not from the slides.
• Transverse section: the TLF has posterior, middle and anterior layers around ES, multifidus and QL, with TA, IO and EO joining at the lateral raphe.

Muscle control in the cervical spine

• The head pivots on the occipito-atlantal jointsOccipito-atlantal jointsThe joints between the base of the skull (occiput) and the first neck vertebra (atlas).General meaning, not from the slides.
• The head’s centre of gravity is anterior to the joint axis → a flexion momentFlexion momentA turning force that tends to bend a part forward.General meaning, not from the slides, balanced by the cervical extensorsCervical extensorsThe muscles at the back of the neck that tilt the head and neck backward.General meaning, not from the slides (upper trapezius and cervical erector spinae/semispinalisSemispinalisA deep back and neck muscle that extends the head and spine.General meaning, not from the slides).
• Tension and fatigue in these and in levator scapulae are felt by most people with posturalPostural syndromeRelating to posture. In McKenzie's system, a syndrome of normal tissues where pain comes from static loading at end-range, not movement, and is never referred. head and neck stress.
• Multifidus has a local stabilizing role in the neck, as in the lumbar spine.
• Jaw position and masticatory muscleMasticatory musclesThe chewing muscles of the jaw.General meaning, not from the slides tension depend on the posture of the head on the neck.

Mandibular elevatorsMandibular elevatorsThe muscles that close the jaw: masseter, temporalis and medial pterygoid.General meaning, not from the slides (masseterMasseterA strong cheek muscle that closes the jaw.General meaning, not from the slides, temporalisTemporalisA fan-shaped muscle on the side of the head that closes the jaw.General meaning, not from the slides, medial pterygoidMedial pterygoidA muscle on the inner side of the jaw that helps close it.General meaning, not from the slides) keep the jaw partially closed at rest.

SuprahyoidSuprahyoid and infrahyoid musclesMuscle groups above (supra-) and below (infra-) the hyoid bone in the neck. They help swallowing and move the jaw and neck.General meaning, not from the slides and infrahyoid groups:

• Help swallowing and balance the jaw against the masticatory muscles; flex the neck when rising from supineSupineLying face up, on the back.General meaning, not from the slides.
• In forward head postureForward head postureA posture in which the head sits forward of the shoulders.General meaning, not from the slides, they and the longus colli become stretched and weak, so the person lifts the head with the SCM.
• In forward head posture the suprahyoids pull the mandibleMandibleThe lower jaw bone.General meaning, not from the slides into depressionDepressionMoving a body part downward, such as lowering the jaw.General meaning, not from the slides, which the elevators counteract with sustained contraction to keep the mouth closed.

Deep craniocervical flexorsDeep craniocervical flexorsThe deep muscles at the front of the upper neck that flex the head and neck and support the spine.General meaning, not from the slides (rectus capitis anterior and lateralis, longus colli, longus capitisLongus capitisA deep muscle at the front of the neck that flexes the head.General meaning, not from the slides):

• Segmental attachments; dynamic support of the neck and head.
• Longus colli: important for axial extensionAxial extensionLengthening the neck upward by drawing the head back (retraction).General meaning, not from the slides (retractionRetractionPulling a part backward, for example drawing the head and chin back over the neck.General meaning, not from the slides); works with the SCM in cervical flexion.
• Without longus colli, the SCM would increase cervical lordosisLordosisThe normal inward curve of the lower back or neck. Increased lordosis means the curve is exaggerated.General meaning, not from the slides when trying to flex.

Role of muscle endurance

• Strength matters for large or unpredictable loads (heavy work, sport, falls), but only ~10% of maximum contraction gives stability in usual situations.
• Slightly more is needed in a segment damaged by disc disease or ligament laxityLigament laxityLooseness of the ligaments, so the joint moves more than normal.General meaning, not from the slides.
• Poor back extensorBack extensorsThe muscles along the spine that straighten the back.General meaning, not from the slides endurance is strongly associated with LBPLBPLow back pain.General meaning, not from the slides.
• All back muscles have more type I than type IIType II fibresFast-twitch muscle fibres, built for quick, forceful movements.General meaning, not from the slides fibres, reflecting their postural/stabilizing role.

Neurological control

• The nervous system coordinates the trunk muscles’ response to expected and unexpected forces, at the right time and by the right amount, by modulating stiffness and movement.

Feed-forward controlFeed-forward controlThe CNS activates trunk muscles before limb movement to keep the spine stable.:

• The CNSCNSCentral nervous system: the brain and spinal cord.General meaning, not from the slides activates trunk muscles before limb movement to keep the spine stable.
• Anticipatory activation of transversus abdominis and deep multifidus is independent of the direction or speed of the disturbance.
• Superficial trunk muscles vary with the direction of limb movement (their guy-wire role controls the centre of massCentre of massThe point at which the body's mass is balanced.General meaning, not from the slides).
• In LBP patients: delayed TrA recruitmentRecruitmentThe switching on of muscle fibres or muscles to do a task.General meaning, not from the slides in all directions, and delayed recruitment of rectus abdominis, erector spinae and obliques specific to the movement direction.

Effects of limb function on spinal stability

Without spinal stabilization, limb-girdle muscles transmit force proximallyProximalCloser to the trunk or the point of attachment of a limb; proximally means in that direction.General meaning, not from the slides and move the spine, overstressing it. Clinical tips:

• Hip flexion: the abdominalsAbdominalsThe muscles of the abdominal wall.General meaning, not from the slides stabilize the pelvis and lumbar spine against the iliopsoas pull, preventing increased lordosis and anterior shearShearA force that tries to slide one layer over another, for example one vertebra over the next.General meaning, not from the slides.
• Pushing: intercostalsIntercostalsThe small muscles between the ribs.General meaning, not from the slides and abdominals stabilize the ribs so pectoralis majorPectoralis majorThe large chest muscle that pulls the arm forward and across the body.General meaning, not from the slides and serratus anteriorSerratus anteriorA muscle along the side of the rib cage that holds the shoulder blade against the ribs and helps push forward.General meaning, not from the slides can push effectively.
• Lifting and pulling: longus colli stabilizes the neck so the upper trapezius doesn’t cause excessive lordosis.

Localized fatigue and muscle imbalance

• Stabilizer fatigue comes from repetitive activity, heavy exertion or faulty posture, and raises injury risk.
• Prolonged repetitive lifting changes spine–lower limb motion and recruitment patterns, increasing anterior/posterior shear in the lumbar spine.
• Imbalances in flexibility and strength of the hip, shoulder and neck muscles put asymmetrical forces on the spine → faulty posture.

Intra-abdominal pressure (IAP) and the Valsalva manoeuvre

• In the Valsalva manoeuvre, TrA, IO and EO contract and raise IAPIntra-abdominal pressure (IAP)Pressure inside the abdomen. A rise in IAP helps unload the spine and tension the TLF, which contributes to stability..
• TrA alone pushes the abdominal contents up against the diaphragmDiaphragmThe dome-shaped breathing muscle under the lungs, separating the chest from the abdomen.General meaning, not from the slides, so the diaphragm and pelvic floorPelvic floorThe muscles that form the base of the pelvis, supporting the organs above.General meaning, not from the slides contract in synchrony with TrA to close the chamber.
• How IAP helps stability:
  • Unloads compressive forces on the spine
  • Pushes out against the abdominals, improving their length–tension relationshipLength–tension relationshipHow much force a muscle can produce at different lengths.General meaning, not from the slides and tensioning the TLF
  • May prevent buckling of the spine
• High IAP → more TLF tension → more stability; low IAP → less.

Valsalva cautions:

1. Common when lifting heavy loads, but has cardiovascular risks, so teach patients to exhale while keeping the abdominal contraction.
2. Holding the breath while contracting the abdominals delays TrA activation; since TrA is needed for segmental stability, exhaling during exertion reinforces stability.

Impaired posture may be the cause of pain, or the result of a traumatic or pathological event.

Core muscle training (practical)

Exercise for muscle performance, endurance and function is built on a base of activating the deep segmental and global stabilizers:

• Deep segmental activation — cervical and lumbar
• Global stabilizationGlobal stabilizationTraining the large, superficial trunk muscles to steady the spine.General meaning, not from the slides — cervical and lumbar
• Stabilization with cardiopulmonaryCardiopulmonaryRelating to the heart and lungs.General meaning, not from the slides endurance
• Stabilization with functional training
• Transitional stabilization exercises

TrA training examples (slide):

• Drawing-in manoeuvreDrawing-in manoeuvreA TrA exercise in which the lower abdomen is gently drawn in toward the spine.General meaning, not from the slides in hook-lyingHook-lyingLying on the back with the knees bent and the feet flat.General meaning, not from the slides, tactile cueTactile cueA touch used as a prompt to help the patient feel the right muscle working.General meaning, not from the slides just medial to the ASISASISAnterior superior iliac spine: the bony point at the front of the pelvis.General meaning, not from the slides; work toward 10-second holds × 10 reps, at least 3 times a day, then TrA isometricsIsometricA muscle contraction in which the muscle tenses but the joint does not move.General meaning, not from the slides in other positions.
• With TrA pre-setTrA pre-setContracting the TrA before the movement begins and holding it during the movement.General meaning, not from the slides and held: hook-lying marchingHook-lying marchingFrom hook-lying, lifting one foot at a time off the surface as if marching, while holding the TrA.General meaning, not from the slides, bent-knee fall-outBent-knee fall-outFrom hook-lying, letting one bent knee fall out to the side and then returning it.General meaning, not from the slides, straight leg raiseStraight leg raiseLifting a straightened leg off the surface.General meaning, not from the slides, prone hip extensionProne hip extensionLying face down and lifting the leg backward at the hip.General meaning, not from the slides over a pillow, side-lying clamshellSide-lying clamshellLying on one side with the knees bent and opening the top knee like a clamshell, without rotating the pelvis.General meaning, not from the slides (pelvis must not rotate).
• Pressure biofeedbackPressure biofeedback (Stabilizer)A device with an air-filled pressure cuff and gauge that gives feedback on lumbopelvic steadiness. (Stabilizer™) gives feedback on lumbopelvicLumbopelvicRelating to the lumbar spine and the pelvis together.General meaning, not from the slides steadiness.

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Part 3 — Spinal Traction

Definition

Spinal tractionSpinal tractionTraction forces applied to the cervical and lumbar spine through mechanical systems such as tables, pulleys, cables and weights, to treat neck and back pain. = tractionTractionA pulling force applied to the spine or a limb.General meaning, not from the slides forces applied to the cervicalCervicalRelating to the neck, the top part of the spine.General meaning, not from the slides and lumbarLumbarRelating to the lower back, the part of the spine between the chest and the pelvis.General meaning, not from the slides spine through mechanical systems: tables, pulleys, cables and weights, to treat neck and back pain.

Effects (flowchart)

Mechanical energy → traction force →

• Spinal column elongation · increased intervertebral space
• Enlarged intervertebral foramenIntervertebral foramenThe opening between two vertebrae where a spinal nerve leaves the spinal canal.General meaning, not from the slides · decreased intradiscal pressureIntradiscal pressureThe pressure inside the intervertebral disc.General meaning, not from the slides
• Nutrient diffusion into the disc · retractionRetractionPulling a part backward, for example drawing the head and chin back over the neck.General meaning, not from the slides of bulging disc material
• Release of pressure on nerve roots · stretch of intervertebral ligaments
• Stretch of paravertebral musclesParavertebral musclesThe muscles that lie alongside the spine.General meaning, not from the slides · increased blood circulation
• Decreased pain · decreased muscle spasm → Enhanced spinal mobility and function

Therapeutic effects and indications

N.B. How long any biomechanical or physiological effect lasts is not known.

Types of traction

MotorizedMotorized tractionTraction in which a motor produces the pulling force.General meaning, not from the slides · PneumaticPneumatic tractionTraction in which air pressure produces the pulling force.General meaning, not from the slides · WeightedWeighted tractionTraction in which weights produce the pulling force.General meaning, not from the slides · AutotractiveAutotractive tractionTraction in which the patient produces the pulling force themselves.General meaning, not from the slides · PositionalPositional tractionTraction produced by placing the patient in a position, with supports such as pillows, blocks or sandbags.General meaning, not from the slides · InvertedInverted tractionTraction in which the patient is tilted head-down, so that body weight provides the pull.General meaning, not from the slides · ManualManual tractionTraction applied by the therapist's hands.General meaning, not from the slides

Contraindications (and why)

Precautions

1. Pain exacerbation → stop and reassess.
2. Previous spinal surgery.
3. SpondylolysisSpondylolysisA defect in the pars interarticularis, the bridge of bone in the vertebral arch.General meaning, not from the slides and spondylolisthesisSpondylolisthesisForward displacement of a vertebra over the vertebra below.General meaning, not from the slides → may cause hypermobility; monitor closely.
4. Respiratory and hypertensive disorders → watch for distress at first application.
5. Dentures → use an occipital halterOccipital halterA harness for cervical traction that pulls through the back of the head (occiput) only.General meaning, not from the slides only (not occipitomandibularOccipitomandibular halterA harness for cervical traction that pulls through both the back of the head and the jaw.General meaning, not from the slides).
6. TMJTMJTemporomandibular joint: the jaw joint, in front of the ear.General meaning, not from the slides dysfunction → occipital halter only.

ContraindicationContraindicationA condition in which a treatment should not be used, because it could cause harm.General meaning, not from the slides vs precautionPrecautionA condition in which a treatment may be used, but only with extra care and close monitoring.General meaning, not from the slides: severe herniation, instability and uncontrolled hypertension are contraindications; spondylolisthesis, previous surgery and controlled hypertensive/respiratory problems are precautions.

Clinical tips

• Cervical traction benefits most: patients > 55 years with positive cervical distraction testCervical distraction testA test in which the examiner gently lifts the patient's head to take pressure off the neck; relief of symptoms is a positive result.General meaning, not from the slides, nerve tension testsNerve tension testsTests that stretch a nerve to see whether they reproduce the patient's symptoms.General meaning, not from the slides, shoulder abduction testShoulder abduction testA test in which the patient rests the hand on top of the head; relief of arm symptoms is a positive result.General meaning, not from the slides and peripheralizationPeripheralizationSymptoms moving distally, away from the spine and down the limb..
• Lumbar traction benefits most: patients > 30 years with no neurological deficitNeurological deficitLoss of nerve function, such as weakness, numbness or loss of reflexes.General meaning, not from the slides.
• For acute disc lesions (cervical or lumbar): sustained tractionSustained tractionA steady pull held for the whole treatment time.General meaning, not from the slides ≤ 10 minutes, intermittent tractionIntermittent tractionA pull that is applied and released repeatedly during treatment.General meaning, not from the slides ≤ 15 minutes.