post operative lumber disc prolapse!!!

[sdkashif]

For cervical Disc Prolapse follow the suggestions as below.

The physiotherapy management programme has been divided in to the different phases according to the severity of the condition. Have a look over that.

Acute Phase:

During this stage physical therapy involves teaching the patient proper posture, body mechanics, how to implement an effective exercise programme, reducing forces compressing the nerve root by relative rest,avoiding positions that increase arm or neck symptoms, to relive pain and dysfunction, promote healing and recovery. This is achieved by the folllowing.

Passive Modalities:

Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (eg, moist-heat packs) or mechanisms for deep-heat transfer (eg, ultrasound, diathermy).

Cervical Traction:

Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.

Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.

The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:

In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 l) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.

Have a look over a very useful article on Cervical Traction.

http://www.thesaundersgroup.com/cervical.pdf

Cervical Immoblization:

Cervical Immoblization with Cervical collar and cervical pillow are commom measure to relieve the neck pain and pain from sub occipital region. The collar commonly prescribed are philadelphia collar, soft cervical collar, hard cervical collar. They are usually prescribed for short period of time and as the symptoms improve, their use is often discarded. A home exercise programme of cervical isometric exercises may help to keep improve the tone loss resulting from cervical immoblization.

Exercises:

An exercise programme based on McKenzie Method may improve the early recovery and function.

The McKenzie Method is not merely extension exercises. In its truest sense, McKenzie is a comprehensive approach to the spine based on sound principles and fundamentals that when understood and followed accordingly are very successful. In fact, most remarkable, but least appreciated, is the McKenzie assessment process.

Assessment. Unique to the McKenzie Method is a well-defined algorithm that leads to the simple classification of spinal-related disorders. It is based on a consistent "cause and effect" relationship between historical pain behavior as well as the pain response to repeated test movements, positions and activities during the assessment process.

A systematic progression of applied mechanical forces (the cause) utilizes pain response (the effect) to monitor changes in motion/function. The underlying disorder can then be quickly identified through objective findings for each individual patient. The McKenzie classification of spinal pain provides reproducible means of separating patients with apparently similar presentations into definable sub-groups (syndromes) to determine appropriate treatment.

McKenzie has named these three mechanical syndromes: Postural, Dysfunction and Derangement.

Postural: End-range stress of normal structures

Dysfunction: End-range stress of shortened structures (scarring, fibrosis, n.root adherence)

Derangement: Anatomical disruption or displacement within the motion segment

(All three mechanical syndromes – postural, dysfunction, and derangement – occur in the cervical as well as thoracic and lumbar regions of the spine.)
Each distinct syndrome is addressed according to it unique nature with mechanical procedures utilizing movement and positions. The Derangement syndrome where the phenomenon of "centralization" occurs is most common.

Well-trained McKenzie practitioners will be able to identify those more difficult cases where advanced McKenzie techniques might benefit the patient versus those patients whose diagnosis is non-mechanical in nature, and those patients are then quickly referred for alternate care, thus avoiding unnecessary periods of inappropriate or expensive management.

Treatment. McKenzie treatment uniquely emphasizes education and active patient involvement in the management of their treatment in order to decrease pain quickly, and restore function and independence, minimizing the number of visits to the clinic. And if a problem is more complex, self-treatment may not be possible right away. However, a certified McKenzie clinician will know when to provide additional advanced hands-on techniques until the patient can successfully manage the prescribed skills on their own.

Ultimately, most patients can successfully treat themselves when provided the necessary knowledge and tools. An individualized self-treatment program tailored to the lifestyle of the patient puts the patient in control safely and effectively.

For detail See McKenzie Mechanical Diagnosis and therapy

Recovery Phase:

Once pain and inflammation are controlled, the patient's therapy should be progressed to restoration of full ROM and flexibility of the neck and should girdle muscles. This phase of rehabilitation focuses on soft tissue overload and biomechanical dysfunction. Goals of this phase are to eliminate pain, normalize spinal mechanics, and improve neuromuscular control of the injured cervical spine. Restoration of the resting muscle length and full, pain-free, cervical ROM are necessary. Strengthening exercises start in simple planes and progress to complex muscle patterns. The techniques are methods used are Cervicothoracic stablization, Neuromobilizations (Butler Approach), Cervical Mobilization and cervical manipulation, soft tissue mobilization or massage and functional restoration, aerobic conditioning.

Cervicothoracic stabilization:

It limits pain, maximizes function, and prevents further injury. Such stabilization includes cervical spine flexibility, postural training, and strengthening. This program emphasizes patient responsibility through active participation.

Restoring flexibility prevents further repetitive microtrauma from poor movement patterning. Pain-free ROM is determined by placing the cervical spine in positions that produce and relieve symptoms. Initially, stabilization commences within established pain-free ROM and then progresses outside this ROM as pain diminishes. Soft tissue or joint restriction inhibiting ROM is treated quickly. Anterior and posterior neck muscles are stretched. Indeed, such spine and soft tissue mobilization, passive ROM, self-stretching, and correct posturing collectively restore ROM.

Postural training commences with the patient, supervised by a therapist, in front of a mirror. The patient performs various transfer maneuvers while maintaining a neutral spine (ie, correct posturing) with feedback from the mirror and the therapist. Patient goals include maintenance of neutral spine and demonstrating correct posture during daily activities.

These proprioceptive skills, implemented during strengthening exercises, facilitate stable, safe, and pain-free cervical posture during strenuous activity. Indeed, cervicothoracic stabilization requires strengthening and coordination of neck, shoulder, and scapular muscles. Cervical muscles include extensors, flexors, rectus capitis anterior, rectus capitis lateralis, longissimus cervicis, and longissimus capitis. Primary thoracic stabilizers include abdominals, lumbar paraspinal extensors, and latissimus dorsi. Scapular muscles include the middle and lower trapezius, serratus anterior, and rhomboids. Chest muscles include the pectoralis major and minor. Successful stabilization also requires the training of the lumbar spine and lower extremities, which provide a foundation for the cervicothoracic spine.

Stabilization exercises proceed systematically from simple to complex. Isometric and isotonic resistive exercises employ elastic bands, weight machines, and free weights. Such conditioning distributes forces away from the cervical spine. Exercise repetition ultimately encodes an engram that commands immediate, automatic cervicothoracic stabilization during everyday activity.

Spinal manipulation and mobilization:

It may restore normal ROM and decrease pain; however, no clear therapeutic mechanism of action is known. Some believe that zygapophysial joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems.

Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction.

No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder.

Spinal manipulation: Its safety is uncertain

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity.


Neuro Moblizations:

Butler's therapy techniques treat radicular symptoms by mobilizing the involved nerve. First, the therapist identifies "adverse neural tension," defined as pathological mechanical and physiological responses elicited from a nerve when its stretch properties and ROM are evaluated. Specifically, the therapist performs neurodynamic testing to evaluate a nerve's mechanical properties (eg, its mobilization around neighboring intervertebral discs) and physiological characteristics (eg, its response to ischemia, inflammation). Having tested the nerve in question, the therapist then may institute treatment consisting initially of passive mobilization to provide CNS input without inciting a stress response and neurogenic massage to reduce perineural swelling. Later, the therapist progresses to active neuromobilization because, according to Butler, recovering nervous tissue (like other connective tissue) requires movement to promote healing and restoration of optimum mechanical properties.

Limited evidence suggests that neurodynamic mobilization improves clinical outcomes. However, optimizing tissue health and cardiovascular fitness, as well as minimizing negative beliefs and environmental factors, can be beneficial.

Functional Restoration:

Functional restoration programs assist patients disabled by chronic cervical pain overcome obstacles to recovery. Such obstacles include deconditioning, secondary gain, poor motivation, and psychopathology.

Aerobic Connditioning:

It also plays a role in reduction of Pain.


Maintenance Phase:

This phase requires proper function pain free ROM, proper spinal and shoulder girdle mechanics. Emphasis is placed on continually achieving and improving strength, flexibility and mobility. Neck and shoulder girdle muscles should be stretched and strengthened by routine exercises. Proper head and neck positioning is maintained in every day activities.


For Lumbar Disc Problems Postoperatively:

Please start an exercise programme to regain the mobility, flexibility and strength of lumbosacral spinal region. Strengthen the lumbar flexors and abdominal muscles.

[junior_physiotherapist]

In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 l) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.......


HI All
Regarding Mr Sdkashif,At first thanks alot of sir for ur intersting & informative posts...
Now i'm wondering about the tractional wieght u wrote them ,since i think they are too large weigth ,i know basically we apply a traction force for head eqaul to it's third wiegth ,so total wight of head is =(20-25)Kg.

As usually we apply athird to half of that wieght which is(8-12)Kg.
as wieght of body'll stabilize her body .
*again secondly how i can give her a tracion and she had a post operative lumber disc prolapse since 6 months( so can i give it to her what about tension of trapeziuse muscles as a result of traction force!!)

Any notes appreciated really..

Regards

[sdkashif]

In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 lb) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions

The references for above mentioned text are:

Therapeutic Exercises, Foundation and Techniques, 3rd Edition by Kisner & Colby

Mobilization of Spine by G.P.Grieve, Fifth Edition

So they are quite authentic references and no doubt about them


Junior Physio as you said,

total wight of head is =(20-25)Kg.

As usually we apply athird to half of that wieght which is(8-12)Kg.
as wieght of body'll stabilize her body .

Is it the weight of head or the weight of a trunk or lower limb. I guess that you are wrong in that case because the total weight of the head is not as that large. The weight of the head is 7% of the total body weight for average individual with normal body weights usually. That figures don't apply to the individuals who are very much over weight. So if an individual has a body weight of 70KG, his head weight will be 4.9Kg or 10.78 lb (pounds). So the spinal traction for pain relieving purposes will be 4.9Kg or 10.78 lb (pounds).

A minimum force of 11.25 to 13.5KG (25 to 30 l) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension.

Actually these figures of traction in the cervical region are used for mechanical separation of the vertebrae as used in reducing the dislocations of subluxations of vertebrae in the spinal region.

[junior_physiotherapist]

[
Actually these figures of traction in the cervical region are used for mechanical separation of the vertebrae as used in reducing the dislocations of subluxations of vertebrae in the spinal region.[/QUOTE]


Hallo,

My question is how i'll apply a traction force for this patient and is just post operative of lumber disc prolabse since 6 months ,,so what about tension which 'll develope in trapeziues mucsles as a result of tracion force


Regards

[sdkashif]

Here are few findings from literature.

These findings are for cervical traction procedures.

Most experiments with poundage above 20lb (9KG), some of very high, separated vertebrae by about 1-1.5mm per space, measured at posterior cervical level.

By far the greatest separation occurs posteriorly and is greatest with increasing flexion.

The normal cervical lordosis is eradicated at pulls of about 20-25 lb (9-11 KG).

A traction force of 30 lb (13.5 KG) for only 7 seconds will separate vertebrae posteriorly, the amount increasing with flexion.

At a constant angle, a traction force of 50 lb (22.5 KG) produces greater separation than 30 lb (13.5 KG) but the amount of separation is not significantly different at 7, 30, 60 seconds.

When separation of vertebral bodies is desired high traction forces with short periods will achieve it.

Upper cervical segments do not separate so easily as lower cervical segments.

Rhythmic traction traction produces twice as much separation as sustained traction.

When traction forces are removed, restoration to normal dimensions is four to five times quicker in posterior structures. Restoration in anterior structures is much slower.

As would be expected less separation occurs in 50 years old patients than in normal 20 years.

Generally for vertebral separation,

In cervical spine, under friction free circumstances, a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5 KG (25 to 30 lb) is necessary to lift the weight of head when sitting and to counteract the resistance of muscular tension. The greatest amount of separation occurs during the first few minutes if treatment at a given forces. For achieving muscle relaxation a traction force is required at level less than those needed for mechnical separation ( 4.5 to 6.75 KG, or 10 to 15 lb) in cervical spine.

In lumbar spine, a minimun friction free force of half the body weight is necessary for mechnical separation. To avoid treatment soreness, the first treatment should not exceed half the patient's weight.

The dosage chosen for the initial treatment should be less than that which cause vertebral separation. Progression of pundage should be determined by patient response and problem being treated.

The duration will depend on the type of traction ( intermittent or sustained), the poundage used, the clinical condition of patient and the goals of treatment.

Traction used for reduction dislocation and subluxation in cervical region are generally higher, up to 140 lb, is used in skeletal traction for reducing the verterae. These figures are very high as compared to spinal traction used for therapeutic pain relieving purpose.

Clinical trials of patients who have under gone one or more surgical procedures 45 % had good pain relief as compared to non surgical group which were 87 %. ( Mobilisation of Spine by G.P.Grieve).

The references for the above mentioned detail are:

Therapeutic Exercises, Foundation and Techniques, 3rd edition, By Kisner and Colby

INITIAL CLOSED REDUCTION OF CERVICAL SPINAL FRACTURE-DISLOCATION INJURIES

Mobilisation of Spine, Fifth Edition by G.P.Grieve.

For additional details please have a look over the attachments with this post.

[junior_physiotherapist]

Hi All


Regarding sdkashif ,thanks alot of for ur informative posts...

Regards

[sdkashif]

Thanks for your comments.