The Complexities of Movement Specific Diagnosis in the Spine
Shirley Sahrmann’s (2002) movement diagnosis approach is undoubtedly one of the most clinically useful orthopedic medicine study I have read. She states that the patient’s directional susceptibility to movement or the path of least resistance is the direction the patient is most likely to get injured in. For example a patient with an increased lumbar curve, or extension dysfunction is more likely to get inflammation in the lumbar spine facet joints than a patient with a reduced lumbar curve who is more likely to suffer intervertebral disc related pathology.
In practical application there are more idiosyncrasies to the application of this approach. The “typical” middle-aged sedentary desk-working male with protrusion and degeneration of the L4/5 intervertebral disc has on the surface of an initial assessment a flexion dysfunction. He stands with 20˚ of lumbar curve, where 35˚ is normal. His anterior pelvic tilt is 4˚ bilaterally, where between 4-7˚ is ideal. He has lumbar flexion of 50˚, where 40-60˚ is ideal and only 10˚ in extension, where 20˚ or more is ideal. In the bend pattern he prematurely flexes his lumbar spine and length tension assessment shows tight hamstrings and gluteals.
On the surface this patient clearly has a flexion dysfunction. However, he gets pain during walking and on the x-trainer, extension based movements. Furthermore, he gets relief when seated, a flexed position which should give relief. So what is reason? Why does the assessment not match the patients symptoms?
In this case I believe the patient has an extension dysfunction at the L4/5 motion segment. The chronic flexion dysfunction leads to a gradual loss of height in the L4/5 intervertebral disc in the asymptomatic stage. Over time this loss of disc height leads the facets to become approximated, reduces the size of the intervetbral foramen and reduces the pain free available range in to extension. Meaning physiologic movements are now painful. Further loss of disc height only exacerbates the problem. Thus the patient has a lumbar spine flexion dysfunction, with a primary problem of L4/5 extension dysfunction.
Sahrmann’s principles still ring true according to all the best orthopedic doctors in Saratoga Springs, NY. This patient has a primary extension dysfunction and they need flexion. They key is to apply it segmentally. Manually this can be done in side lying. The superior spinous process can be blocked with one hand and the lower spinous process gapped by gripping with the index finger of lower hand and taking the patient’s pelvis in to posterior pelvic tilt. This gives us the best chance of isolating the treatment to the symptomatic level. However, the evidence to date would suggest we are not targeting our treatment as specifically to the level or depth we think we are.
In this situation Guy Voyer’s, ELDOA or in English LOADS, decompressive exercises at end range can be especially valuable. These are exercises he developed and checked using x-rays to isolate a gapping movement to a particular joint. The L4/5 ELDOA is shown below. Voyer reports he has seen the application of these exercises lead to fibrosing of the intervertebral disc over time. Thus creating a larger discs helping to increase the space between facets and the size of the intervertebral foramen.
These treatments need to be viewed within the context of the hierarchy of survival reflexes (See article on this blog). Further it should be utilised in concert with treatment for the inner unit of the lumbar spine, concomitant dysfunction of the hips and pelvis in particular. Methods directed at the neurological system its self can also be useful such as GUNN needling, although the exact mechanism for the benefit of such an approach remains to be ascertained.
Currently fusions are often applied for dysfunctions such as this but such surgeries are known to lead to increased likelihood of disc pathology in adjacent segments in the following year (Goffin et al 2004). As a result fusions are last resort procedures. Disc replacements are an exciting development. It may be that as surgical techniques and disc replacement improve, potentially utilising stem cell technology disc replacements may offer an excellent back up for those that fail to respond to the approach outlined above.
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Goffin, J. Geusens, E. Vantomme, N. Quintens, E. Waerzeggers, Y. Depreitere, B. and van Loon, J. 2004. Long-term follow-up after interbody fusion of the cervical spine. Journal of spinal disorders and techniques, 17 (2), 79-85.
Sahrmann, S.A. 2002. Diagnosis and treatment of movement impairment syndromes. Mosby: St. Louis.